Payment Plan Application

Payment Plan Application

PP1

For all payment plan applications please complete this form and click submit. Once submitted it will be reviewed by a Senior Case Manager who will contact you shortly to discuss your application.

YOU MUST HAVE ATTENDED AN INITIAL CONSULTATION AND COMPLETED OUR SERVICE CONSENT FORM BEFORE APPLYING

Personal Details

Please complete all fields regarding yourself, the bill payer and person who will be legally liable for the payment plan.

Title

Surname*

First Name*

Middle Name

Date of Birth*

Date

Address*

Street Address

Street Address Line 2

CityCounty

Post CodeCountry

Mobile Number*

Home Number

Personal Email*

Case Information

Please provide us with details of the service or case you would like the payment plan to be considered for. If you dont have a case number or don't know this yet, please leave this blank.

Case Number

If Known

Service*

What service will the plan relate to?

Case Subject*

MyselfAnother

Name

First NameLast Name

Payment Plan

You will be required to make an initial payment towards your plan before we can deliver any services. This can be any amount of your choosing, however, it must be a minimum of 20% of the plan total. The remaining amounts will be divided over the duration of your plan.

Your first monthly payment will be due in the following calendar month.

What is the total amount for the plan?

If known

Duration*

How many months will the plan be required?

Minimum initial payment

Voluntary Initial Payment*

Please choose your preferred payment date*

You can choose any of the following dates

Remaining Monthly Payments

Proof of Identity

As part of your application we require proof of your identity. Please upload a scanned version of a document that shows your full name and current address. For example:

Driving Licence, Utility Bill, Bank Statement (dated within 3 months)

Please upload your identity document here*

Upload

Payment Information

As part of your application we require a credit/debit card to be provided to us to collect your initial payment. Your card will not be charged until your plan has been agreed and you have signed and completed a payment plan agreement.

If your plan is not agreed you will not be charged and your payment details will be deleted.

Your credit/debit card information is not sent to us with your application but stored encrypted on the servers of Stripe, our payment partner.

Initial Payment Due*

Please provide a credit or debit card to collect your initial payment*

GBPDescription

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Confirmation

Please review your form to ensure you have provided the correct information and when you are satisfied, please click "Submit using Encryption". Your information will be securely transmitted to one of our Case Management Team.

This application will not involve a credit check and will not legally bind you to any financial agreement. Your payment method will not be charged the initial fee until your application has been agreed and you have signed the payment plan agreement form sent to you separately. This application will be reviewed by a Senior Case Manager who will contact you shortly to discuss your application and if successful will send you a pre filled agreement to sign.