Ceredigion Citizens Advice
PERSONAL INFORMATION
Name:
Address:
Postcode:
Nationality:
Date of Birth:
Occupation:
Phone Number:
Email Address:
INSTRUCTIONS
To assist you with the enquiry we would like to collect as much information from you as possible,
with relevance to your problem. All the information you give us will be completely confidential.
Please leave blank any questions you prefer not to answer or that have no relevance to your
problem.
YOUR ISSUE
Description of Problem:
Specialist advice:
At CAB Ceredigion we have a selection of specialist advisors who can help with problems in specific areas. If you have a
specialist enquiry please select the appropriate box below.
Benefits
Debt
Employment
Mental Health issues
Contact:
Do you agree to be contacted by telephone on the number provided
Yes
Physical health issues
No
Please email me
MARITAL STATUS
Please inform us of you current marital status:
Single
Married
Living with Partner
Separated
Divorced
Widowed
HOUSING TENURE
Please inform us of your current housing situation:
Own Outright
Buying home
Shared Ownership
Private tenant
Rent-free housing
Council/ALMO tenant
Staying with relatives/friends
Hostel
Housing assoc/RSL tenant
Prison
Other (please specify)
MONTHLY FINANCIAL PROFILE
Please inform us of you current monthly income:
under £300
£300 - £599
£600 - £999
£1000 - £1499
£1500 - £1999
£2000+
£1000 - £1499
£1500 - £1999
£2000+
Please inform us of you average monthly expenditures:
under £300
£300 - £599
£600 - £999
Homeless