The information you provide below will be loaded into the SAFE Parliamentary Action Group Computer database it will enable us to
produce more accurate statistics for the All Party Parliamentary
Group on Financial Exploitation, MP’s, Treasury, The Various
Governing Bodies and Media we are registered with the Information
Commission and all details are treated as confidential.
Title:
Mr.
Mrs.
Ms
Dr.
First name:
Surname:
Address Line 1:
Address Line2:
City:
County/State:
Postcode/ZIP:
Email:
Phone:
Fax:
Mobile:
We will use your details
as statistics for our reports to the: All Party Parliamentary Group
/ Treasury / Governing Bodies etc.
Are you prepared to go Public
Yes
No
Do you need Assistance:
Yes
No
Case Ongoing
Case Over:
Problem with:
Cause of initial problem:
Were you:
please select one
Director
Sole Trader
Employed
Self Employed
Partner
Husdand or Wife
Other
If other please specify:
Have you lost your business:
Yes
No
If yes, what was the value:
Have you lost your home:
Yes
No
If yes, what was the value:
Other loses:
Court Action:
Yes
No
Case numbers if known:
Result of Court Action:
Their Law Firm:
Your Law Firm:
Legal Aid:
Yes
No
Total amount of certificate:
Privately funded:
Yes
No
Total amount of costs:
Bankruptcy:
Yes
No
Bankruptcy dicharged:
Yes
No
How long were you Bankrupt:
Name and firm of Receiver/ Trustee:
Police investigation:
Yes
No
Crime reference number:
Which Force:
Name of Senior Officer:
Outcome:
Did your marriage Break up:
Yes
No
Other relationships affected:
Yes
No
Are you currently:
please select one
Employed
Self Employed
Retired
On Benefit
Other
Have you contacted your Member of
Parliament :
Yes
No
Who is your MP:
Would you provide under separate cover
a précis of your case as a Statement of Truth, Including details of
court cases judgments and any other relevant information 2-4 pages
A4 max.
Yes
No
Are you willing to be added to the
group’s action in Europe:
Yes
No
Do you want Publicity
Yes
No
Consent:
Yes
No
All donations are
gratefully accepted, as we are not for profit organisation
Secretariat to the All Party Parliamentary Group Against Financial
Exploitation
SAFE is a Company Limited by Guarantee Registered in England and
Wales. No.4853224
Registered office 69 Sutton Road, Heston, Hounslow, London TW5 0PN
Tel: 0208 630 9990 FAX: 0208 630 9900 E-mails:
elainewilliams_safe@blueyonder.co.uk
Website: www.safe-online.org
Download
Form (Word)
Download Form (PDF)
Please print out and return signed Form
with Ł50
Registration to: SAFE
Elaine Williams
*Also press submit button to send this copy to us
