Debt Help Application

This form helps us to gather the relevant information required to assist you with your mortgage and/or debts. Fill in the fields that are relevant to you and send it through. An advisor will be in touch to discuss your circumstances further and to let you know of your available options. All advice is free and confidential.

Step 1 · Monthly Household Income

	You	Your Partner
Income from Salary
Social Welfare Benefit
Mortgage Interest Supplement
Family Income Support
Carers Allowance
Job Seekers Allowance
Maintenance
Pension

Add Income Delete

Step 2 · Monthly Household Expenses

Reasonable living expenses	Please choose so we can determine your expenses
PLEASE NOTE: The Insolvency Service of Ireland have set reasonable living expenses for adults and children which takes into consideration all costs involved for living and travel, so we will apply these expenses for you according to your situation. Please fill out the fields below so we can work out your expenses. If you have any additional expenses, please fill these out too.
Monthly Mortgage or Rent
How many adults live in your house?
Do you have any children or dependents?	Yes No Please enter any ages of dependents (separated with a comma).
Do you own any vehicles?	Yes No How much do you spend per month on fuel?
Additional expenses	You	Your Partner
Childcare
Voluntary Health Insurance (VHI)

Add expense Delete

Step 3 · Your Property Details

Mortgage amount Outstanding
Current House Value
Mortgage Lender
Years remaining on mortgage
Are you in Arrears?	Yes No

Add Property Delete

Step 4 · Credit cards and Loans

#	Creditor Name	Balance Outstanding	Monthly Payment
1

Add Creditor Delete

Step 5 · Personal Details

	You	Your Partner
Full name
Your email address
Contact telephone number
Address
Additional information (Optional)

I would like my information only to be used to advise me and not to be passed to any third parties.

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