Please use this form if our financial support phone line is busy or unavailable. If your query is not about financial support please visit our Help Centre. First name Last name Date of birth DDMMYYYY Email address Confirm your email address House number Your postcode Last 4 digits of your loan or store card account number I can't make a payment because... I've had a loss or reduction in earnings Other Please tell us more about your situation How long do you think you will need payment support for? Less than 30 days More than 30 days but less than 3 months More than 3 months Have you already missed a payment on your account? Yes No Is it likely you'll miss your next Direct Debit or a future payment? Yes No Not applicable We need to ask you some further information about your current circumstances This part of the form asks you for information about your current income and expenditure. If you've completed a similar form with another creditor in the last 30 days, you can attach a copy of that form instead. Are you able to send us a completed form from another creditor? Yes No Please send your completed form to financialsupport@ikano.net Upload your file from another creditor We accept .png, .jpeg, .pdf file formats (maximum file size 10MB) Upload here Your financial circumstances This part of the form will take around 10 minutes to complete. Current financial position Please tell us in more detail about your current financial circumstances Number of dependent children under 16 Number of dependent children over 16 Other dependents Number of people in your household Number of vehicles in your household Housing ownership Owner (no mortgage) Owner (mortgaged) Living with parents Tenant (private) Tenant (social) Other Employment status (You) Full Time Part time Unemployed Not working due to illness or disability Self-employed Retired Other Employment status (Partner) Full Time Part time Unemployed Not working due to illness or disability Self-employed Retired Other Monthly Household Income Please tell us about your monthly household income Your monthly wages / salary (take home pay) £ Partner monthly wages / salary (take home pay) £ Other household monthly income £ Total for household - for example, self-employment £ State / private pension £ Benefits monthly £ (including JobSeekers Allowance, Income Support, Child Benefits, Disability Allowances, Maternity Pay, Statutory Sick Pay) Maintenance or child support £ Boarders or lodgers £ Non-dependant contributions £ Student loans / grants £ Other (please state) Your Monthly Outgoings Please tell us about your essential monthly outgoings Mortgage / rent £ Secured loans £ Service charges or ground rent £ Council tax £ Utility bills £ (gas, electricity, other household fuels (coal, oil), water) £ Appliance and furniture rental £ HP / conditional sale £ Child support / maintenance £ Other (please state) £ Please provide more information here Please tell us about your other monthly outgoings Childcare costs £ Adult care costs £ Child support / maintenance £ Prescriptions / medicines £ Dentistry / Opticians £ Housekeeping £ (including food shopping, clothes, toiletries, baby items including nappies, laundry and dry cleaning, alcohol, smoking products, hairdressing) Telephone (mobile and landline) £ Internet / TV £ Travel expenses monthly £ (public transport, car including hire purchase or conditional sale vehicle, fuel) £ Car monthly spend £ (MOT, servicing, road tax, breakdown cover, parking charges £) Insurance monthly £ (including home, car, medical, life) £ Professional monthly £ (courses, union fees, professional fees £) Hobbies, leisure, sport £ Vets bills and pet insurance £ House repairs and maintenance £ Other (please state) £ Please provide more information here Other Creditors Please tell us about your other Creditors (companies or people you owe money to) 1. Creditor name: Total outstanding debt £ Monthly contractual payment £ 2. Creditor name: Total outstanding debt £ Monthly contractual amount £ 3. Creditor name: Total outstanding debt £ Monthly contractual amount £ 4. Creditor name: Total outstanding debt £ Monthly contractual amount £ If you have more than 4 other creditors, please tell us more: Contact Details If we need to call you back to discuss your current circumstances, please provide the most suitable number and time to call you: Telephone number Best time to call you We will try to contact you at your preferred time, but this may not always be possible. Our opening hours are between 9am and 5:30pm. Thank you We will be in contact within 5 working days to let you know the next steps, and if we need any further details from you.
