Provide details below for a fast assessment.
1. Client Name (Individual / Company) *
2. Contact Person (if company)
3. Email Address *
4. Telephone Number *
5. Client Address / Company Registered Address *
6. Debtor Type * IndividualCompany / LLP
If Individual:
7. Full Name
9. Email Address (if known)
8. Residential Address (last known)
If Company / LLP:
10. Registered Company Name
11. Company Number
12. Registered Office Address
I confirm the registered details match Companies House
13. Trading Address (if different)
14. Debtor Contact Email (if known)
15. Written Agreement / Contract? * YesNo
16. Type of Agreement (if yes) Written contractSigned terms & conditionsEmail agreementPurchase orderOther (please specify)
Other (please specify)
17. Date of Agreement / Contract
18. Governing Law (if known) England & WalesOtherNot stated
If Other, specify
19. Total Amount Outstanding (£) *
20. Number of Invoices *
21. Invoice Details (optional — add up to 3, or upload invoices below)
Tip: If you have many invoices, just upload them.
22. Upload Supporting Documents (optional) InvoicesContract / T&CsStatements of accountEmails / correspondence
Upload files (PDF/DOC/JPG/PNG) – max 10MB each
23. Reason(s) given for non-payment (if any)
24. Disputed in writing? *
YesNo
25. Debtor raised any of the following? Service / goods disputeCounterclaimSet-offInsolvency threatNo response at all
26. Any part payments made? *
If yes, amount and date(s)
27. How long has the debt been outstanding? *
Less than 30 days30–90 days3–6 months6–12 monthsOver 12 months
28. Minimum acceptable settlement (£) *
29. Accept instalments? *
YESNo
30. Instructions / sensitivities
The information provided is accurate to the best of my knowledgeThe debt is due and payableI authorise you to contact the debtor on my behalf
Anything else? (optional)
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