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Loan application form

I am applying for:

Amount requested:

Membership number: *

Name *

First

Last

Address: *

Number of years at this address: *

Previous address (if under three years):

Telephone numbers: *

Mobile and/or landline.

Email *

Email

Confirm Email

Number of dependent children: *

… and their ages. If you have any.

Marital status

Single
Married
Separated
Divorced
Widowed
Living with partner

Housing

Homeowner
Council tenant
Private tenant
Other living arrangements

Name of landlord:

If you have one.

Employment

Employed
Unemployed
Self employed
Retired

Name of employer:

If appropriate.

Years of service:

If appropriate.

Have you ever served in HM armed forces?

Yes
No

Please let us know…

I have County Court Judgements
I have been declared bankrupt
I have or am considering a Debt Relief Order
I make weekly or monthly repayments or items or services
I have previously had a social fund loan
I have rent or council tax arrears
I have other outstanding debts

Income from employment *

Per… *

Icome from partner's employment *

Per… *

Income from child benefits *

Per… *

Other incomes

If you have any.

Per… *

Spending on car repayments *

If any.

Per… *

Spending on car tax *

If any.

Per… *

Spending on car insurance *

If any.

Per… *

Spending on car repairs *

If any.

Per… *

Spending on car fuel *

If any.

Per… *

Please detail all items on finance and credit cards *

If any.

Spending on mortgage or rent *

Per… *

Spending on council tax *

Per… *

Spending on electricity bills *

Per… *

Spending on gas bills *

Per… *

Spending on water bills *

Per… *

Spending on groceries and houseland goods *

Per… *

Spending on clothing and footwear *

Per… *

Spending on mobile & landline telephone *

Per… *

Spending on internet services *

Per… *

Spending home insurance *

Per… *

Spending on savings or pension payments *

Per… *

Spending on medical expenses *

Per… *

Spending on holidays *

Per… *

Spending on birthday and Christmas presents *

Per… *

Spending on social life (inc. treats & takeaways) *

Per… *

Spending on hobbies and sports *

Per… *

Spending on lottery and gambling *

Per… *

Spending on subscriptions & membership fees *

Per… *

Spending on alcohol *

Per… *

Spending on childcare payments *

Per… *

Spending on school meals *

Per… *

Spending on children's activities & pocket money *

If any.

Per… *

Spending on hair dressing & beauty treatments *

If any.

Per… *

Spending on pets *

If any.

Per… *

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