Equita Ref Number*

Customer Name*

Postcode*

Are you the account holder?*
YesNo

Select the most relevant description of your vulnerability from the list below*
Is elderly, frail or confusedHas a physical or sensory impairmentHas a learning disability or mental health illnessIs seriously illIs recently bereavedIs a single parent familyIs in the latter stages of pregnancy, or has recently given birthHas obvious difficulty in understanding, speaking or reading EnglishIs living in financial hardship or povertyHas substance abuse addictionsHas found themselves in difficult circumstances through CoronavirusDomestic or Financial AbuseSuicidal or Self-Harm Declaration

Select the best time and day for our welfare experts to call you about your case*
Monday 10am-12pmMonday 2pm-4pmTuesday 10am-12pmTuesday 2pm-4pmWednesday 10am-12pmWednesday 2pm-4pmThursday 10am-12pmThursday 2pm-4pmFriday 10am-12pmFriday 2pm-4pm

Enter the best phone number for us to call or give us your email address.

Preferred method of contact*
EmailTelephone

Email Address*

Telephone*

Is there anything we need to know about when we call you?
Eg I use an induction loop or Sign Language interpreter.

Decision

To allow us to help you we may need to see supporting documents for your situation.

Examples of acceptable documentation:

• Doctor or Hospital letter detailing your symptoms/condition

• Documents supporting a recent event, for example redundancy/bereavement

• Documents showing that you are a victim of crime

• Documents showing that you have a current Individual Voluntary Arrangement/Debt Relief Order/Bankruptcy

Sharing of information

We may disclose your personal data to our instructing Clients, agents who we use to collect what you owe or where we have a legal obligation or a legitimate interest to do so.

Equita may also share your personal information with the police and other government agencies for the purposes of crime prevention or detection.

If we disclose your information, we ask the organisation to demonstrate that the data will assist in the prevention or detection of crime, or that Equita is legally obliged to disclose it, and written authority is required to ensure we comply with Data Protection.

We confirm we will not send your information outside the EEA.

Do you want to upload your documents now?*
YesNo

Please Note

• Form submissions are checked daily Monday to Friday. We cannot guarantee that enforcement will not continue during this time.

• If we are unable to make contact with you at the time requested enforcement may continue

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