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1 Financial Planner Form Please return completed form to: Collections Department Britannia Britannia House Leek ST13 5RG Once you have completed the form please ensure you sign the declaration before returning. It is important that you provide us with accurate information so that we can help you to meet your commitments; please indicate either weekly, monthly or annual costs. We re always here to help you, so if you have any questions, please contact us on Your details Account Number /s Daytime Telephone No: Evening Telephone No: Mobile Telephone No: Work Telephone No: No of Adults in the Household No of Children (under 18) in the Household Household Income Please include total amount received after any deductions ie: Tax and National Insurance. Paid Work / Weekly / Your take home pay Your partner's take home pay Bonus / Overtime (Regular only) Retirement / Works Pension Income Protection Insurance s Benefits Job Seekers Allowance Income Support Tax Credits Incapacity / Sickness / Disability Child Benefit Other Income Investment Income Rental (lodgers / other properties) Maintenance s Student Loan / Bursary Other (please state)
2 Savings and Investments of Savings easily accessible (Including Redundancy) Value of other Investments (Property, Stocks & Shares) Current Outgoings In this section please tell us about all payments that you are currently committed to paying on a regular basis. Property Costs (including 2nd properties) Mortgage Other Secured Loan(s) Endowment /Investment (to repay Mortgage) Rent / Mortgage on any other property Council Tax Ground Rent / Service Charge /Shared Ownership Rent Utility Costs Water Gas Electricity Other household fuel Insurance Costs Life / Medical Insurance Mortgage / Income Protection Vehicle Insurance / Breakdown Cover Building & Contents Insurance Pet Insurance Travel Insurance
3 Travel Costs Travel Expenses (Fuel / Parking / Fares) Vehicle Tax Vehicle MOT / Servicing Child Costs Childcare Child Support Agency / Maintenance School Meals School Trips / Activities Children s Pocket Money Healthcare Costs Healthcare / Prescriptions Dental / Optical Other Costs Magistrate Court Fines TV Licence Mobile Phone Telephone (Landline) Internet Satellite / Cable TV HP/Rental (Household Appliances) Housekeeping (Food / Toiletries / Cleaning) Pet Food/Expenses (not Pet Insurance) Meals at work Hairdressing Hobbies / Sports / Entertainment Clothing / Footwear
4 Other Costs (continued) Socialising e.g. Cigarettes / Alcohol / Lottery Newspaper / Magazines / Subscriptions Sundries & Emergencies Other (Incl. Pension Contributions) Other Additional Information Here we need to understand your other financial circumstances and help you to think about a repayment plan which will work for you and help you to get back on track with your finances. Personal Finance Costs Name of Creditor Please use the space below to provide us with a background as to why you have been unable to meet your mortgage payments. We need to understand how your circumstances or situation has changed.
5 Useful Telephone Numbers Britannia Collections At Britannia, we are committed to providing a high level of customer service so if you have any further questions, please do not hesitate to contact us on Our lines are open between 8am and 6pm Monday to Friday, and 8am to 1pm on Saturday. You will need your account number for reference. Telephone calls may be recorded and/ or monitored. Britannia is a trading name of the Co-operative Bank Plc, authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Useful Local Services Numbers can be found in the phone book Citizens Advice Bureau: Advice on general matters and Money Advice Centres welfare benefits Law Centre: Offer legal advice on a wide range of issues Trading Standards (Consumer Protection) Departments Welfare Rights Advice Services Department of Work and Pensions Relate This is an accurate record of my/our position at the date of signature. I/We have fully understood the implications of non payment. I/We understand that the information I/we have provided on this form will be retained with my mortgage account records on Britannia s systems and will be used to assess my individual financial needs. I/We understand Britannia will not pass this information to any unauthorised third parties. Signed by all parties to the mortgage: Name: Signature: Date Name: Signature: Date
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