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:

(Please name Bank or Organisation)

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
Director SAFE
69 Sutton Road
Heston, Hounslow,
London TW5 OPN

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