1. About You
Name
Mr.
Mrs.
Miss.
Ms.
Dr.
Hon.
Rev.
Maiden name
Date of birth
dd
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
mm
01
02
03
04
05
06
07
08
09
10
11
12
yyyy
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
Marital status
Please choose...
Divorced
Living with partner
Married
Separated
Single
Widow
Widower
Other
Employment status
Please choose...
Disabled
Employed full-time
Employed part-time
Househusband
Housewife
Retired
Self-employed
Student
Unemployed
Proof of income
Please choose...
Accounts
Tax returns
Self-certification
Time in job
Please choose...
less than a year
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
10 years
11 years
12 years
13 years
14 years
15 years
16 years
17 years
18 years
19 years
20 years
21 years
22 years
23 years
24 years
25 years
26 years
27 years
28 years
29 years
30 years
31 years
32 years
33 years
34 years
35 years
36 years
37 years
38 years
39 years
40 years
41 years
42 years
43 years
44 years
45 years
46 years
47 years
48 years
49 years
50 years
Occupation
Annual income (before tax)
Please choose...
0
£ 1,000
£ 2,000
£ 3,000
£ 4,000
£ 5,000
£ 6,000
£ 7,000
£ 8,000
£ 9,000
£ 10,000
£ 11,000
£ 12,000
£ 13,000
£ 14,000
£ 15,000
£ 16,000
£ 17,000
£ 18,000
£ 19,000
£ 20,000
£ 21,000
£ 22,000
£ 23,000
£ 24,000
£ 25,000
£ 26,000
£ 27,000
£ 28,000
£ 29,000
£ 30,000
£ 31,000
£ 32,000
£ 33,000
£ 34,000
£ 35,000
£ 36,000
£ 37,000
£ 38,000
£ 39,000
£ 40,000
£ 41,000
£ 42,000
£ 43,000
£ 44,000
£ 45,000
£ 46,000
£ 47,000
£ 48,000
£ 49,000
£ 50,000
£ 51,000
£ 52,000
£ 53,000
£ 54,000
£ 55,000
£ 56,000
£ 57,000
£ 58,000
£ 59,000
£ 60,000
£ 61,000
£ 62,000
£ 63,000
£ 64,000
£ 65,000
£ 66,000
£ 67,000
£ 68,000
£ 69,000
£ 70,000
£ 71,000
£ 72,000
£ 73,000
£ 74,000
£ 75,000
£ 76,000
£ 77,000
£ 78,000
£ 79,000
£ 80,000
£ 81,000
£ 82,000
£ 83,000
£ 84,000
£ 85,000
£ 86,000
£ 87,000
£ 88,000
£ 89,000
£ 90,000
£ 91,000
£ 92,000
£ 93,000
£ 94,000
£ 95,000
£ 96,000
£ 97,000
£ 98,000
£ 99,000
£ 100,000
£ 110,000
£ 120,000
£ 130,000
£ 140,000
£ 150,000
£ 160,000
£ 170,000
£ 180,000
£ 190,000
£ 200,000
more than £ 200,000
Do you have any additional
income?
No
Yes
How much is this annually?
Please choose...
0
£ 1,000
£ 2,000
£ 3,000
£ 4,000
£ 5,000
£ 6,000
£ 7,000
£ 8,000
£ 9,000
£ 10,000
£ 11,000
£ 12,000
£ 13,000
£ 14,000
£ 15,000
£ 16,000
£ 17,000
£ 18,000
£ 19,000
£ 20,000
£ 21,000
£ 22,000
£ 23,000
£ 24,000
£ 25,000
£ 26,000
£ 27,000
£ 28,000
£ 29,000
£ 30,000
£ 31,000
£ 32,000
£ 33,000
£ 34,000
£ 35,000
£ 36,000
£ 37,000
£ 38,000
£ 39,000
£ 40,000
£ 41,000
£ 42,000
£ 43,000
£ 44,000
£ 45,000
£ 46,000
£ 47,000
£ 48,000
£ 49,000
£ 50,000
£ 51,000
£ 52,000
£ 53,000
£ 54,000
£ 55,000
£ 56,000
£ 57,000
£ 58,000
£ 59,000
£ 60,000
£ 61,000
£ 62,000
£ 63,000
£ 64,000
£ 65,000
£ 66,000
£ 67,000
£ 68,000
£ 69,000
£ 70,000
£ 71,000
£ 72,000
£ 73,000
£ 74,000
£ 75,000
£ 76,000
£ 77,000
£ 78,000
£ 79,000
£ 80,000
£ 81,000
£ 82,000
£ 83,000
£ 84,000
£ 85,000
£ 86,000
£ 87,000
£ 88,000
£ 89,000
£ 90,000
£ 91,000
£ 92,000
£ 93,000
£ 94,000
£ 95,000
£ 96,000
£ 97,000
£ 98,000
£ 99,000
£ 100,000
£ 110,000
£ 120,000
£ 130,000
£ 140,000
£ 150,000
£ 160,000
£ 170,000
£ 180,000
£ 190,000
£ 200,000
more than £ 200,000
What is the source of this
income?
2. Contact details
Phone number
Email Address
If we need to call you, what
time is best?
Please choose...
08:00
08:30
09:00
09:30
10:00
10:30
11:00
11:30
12:00
12:30
13:00
13:30
14:00
14:30
15:00
15:30
16:00
16:30
17:00
17:30
18:00
18:30
19:00
19:30
20:00
Address
Mother’s maiden name
(for security)
3. Your home
Is your home jointly owned?
Yes
No
Home value
Please choose...
£ 10,000
£ 20,000
£ 30,000
£ 40,000
£ 50,000
£ 60,000
£ 70,000
£ 80,000
£ 90,000
£ 100,000
£ 110,000
£ 120,000
£ 130,000
£ 140,000
£ 150,000
£ 160,000
£ 170,000
£ 180,000
£ 190,000
£ 200,000
£ 210,000
£ 220,000
£ 230,000
£ 240,000
£ 250,000
£ 260,000
£ 270,000
£ 280,000
£ 290,000
£ 300,000
£ 310,000
£ 320,000
£ 330,000
£ 340,000
£ 350,000
£ 360,000
£ 370,000
£ 380,000
£ 390,000
£ 400,000
£ 410,000
£ 420,000
£ 430,000
£ 440,000
£ 450,000
£ 460,000
£ 470,000
£ 480,000
£ 490,000
£ 500,000
£ 510,000
£ 520,000
£ 530,000
£ 540,000
£ 550,000
£ 560,000
£ 570,000
£ 580,000
£ 590,000
£ 600,000
£ 610,000
£ 620,000
£ 630,000
£ 640,000
£ 650,000
£ 660,000
£ 670,000
£ 680,000
£ 690,000
£ 700,000
£ 710,000
£ 720,000
£ 730,000
£ 740,000
£ 750,000
£ 760,000
£ 770,000
£ 780,000
£ 790,000
£ 800,000
£ 810,000
£ 820,000
£ 830,000
£ 840,000
£ 850,000
£ 860,000
£ 870,000
£ 880,000
£ 890,000
£ 900,000
£ 910,000
£ 920,000
£ 930,000
£ 940,000
£ 950,000
£ 960,000
£ 970,000
£ 980,000
£ 990,000
£ 1,000,000
more than £ 1,000,000
Year purchased
Please choose...
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
Purchase price
Please choose...
£ 10,000
£ 20,000
£ 30,000
£ 40,000
£ 50,000
£ 60,000
£ 70,000
£ 80,000
£ 90,000
£ 100,000
£ 110,000
£ 120,000
£ 130,000
£ 140,000
£ 150,000
£ 160,000
£ 170,000
£ 180,000
£ 190,000
£ 200,000
£ 210,000
£ 220,000
£ 230,000
£ 240,000
£ 250,000
£ 260,000
£ 270,000
£ 280,000
£ 290,000
£ 300,000
£ 310,000
£ 320,000
£ 330,000
£ 340,000
£ 350,000
£ 360,000
£ 370,000
£ 380,000
£ 390,000
£ 400,000
£ 410,000
£ 420,000
£ 430,000
£ 440,000
£ 450,000
£ 460,000
£ 470,000
£ 480,000
£ 490,000
£ 500,000
£ 510,000
£ 520,000
£ 530,000
£ 540,000
£ 550,000
£ 560,000
£ 570,000
£ 580,000
£ 590,000
£ 600,000
£ 610,000
£ 620,000
£ 630,000
£ 640,000
£ 650,000
£ 660,000
£ 670,000
£ 680,000
£ 690,000
£ 700,000
£ 710,000
£ 720,000
£ 730,000
£ 740,000
£ 750,000
£ 760,000
£ 770,000
£ 780,000
£ 790,000
£ 800,000
£ 810,000
£ 820,000
£ 830,000
£ 840,000
£ 850,000
£ 860,000
£ 870,000
£ 880,000
£ 890,000
£ 900,000
£ 910,000
£ 920,000
£ 930,000
£ 940,000
£ 950,000
£ 960,000
£ 970,000
£ 980,000
£ 990,000
£ 1,000,000
more than £ 1,000,000
Type of property
Please choose...
Bungalow - detached
Bungalow - semi-detached
Bungalow - terraced
Care Home
Chalet/Dormer
Flat
House - detached
House - end of terrace
House - mid terrace
House - terraced
House - semi-detached
Maisonette
Other
Townhouse
Number of bedrooms
Please choose...
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Property construction type
Please choose...
Bricks & mortar
Concrete - panels
Concrete - poured
Mobile home
Steel frame
Stone
Timber framed
Ex-council property?
Yes
No
Did you purchase as a
sitting tenant?
Yes
No
Council’ valuation of property
Please choose...
£ 10,000
£ 20,000
£ 30,000
£ 40,000
£ 50,000
£ 60,000
£ 70,000
£ 80,000
£ 90,000
£ 100,000
£ 110,000
£ 120,000
£ 130,000
£ 140,000
£ 150,000
£ 160,000
£ 170,000
£ 180,000
£ 190,000
£ 200,000
£ 210,000
£ 220,000
£ 230,000
£ 240,000
£ 250,000
£ 260,000
£ 270,000
£ 280,000
£ 290,000
£ 300,000
£ 310,000
£ 320,000
£ 330,000
£ 340,000
£ 350,000
£ 360,000
£ 370,000
£ 380,000
£ 390,000
£ 400,000
£ 410,000
£ 420,000
£ 430,000
£ 440,000
£ 450,000
£ 460,000
£ 470,000
£ 480,000
£ 490,000
£ 500,000
£ 510,000
£ 520,000
£ 530,000
£ 540,000
£ 550,000
£ 560,000
£ 570,000
£ 580,000
£ 590,000
£ 600,000
£ 610,000
£ 620,000
£ 630,000
£ 640,000
£ 650,000
£ 660,000
£ 670,000
£ 680,000
£ 690,000
£ 700,000
£ 710,000
£ 720,000
£ 730,000
£ 740,000
£ 750,000
£ 760,000
£ 770,000
£ 780,000
£ 790,000
£ 800,000
£ 810,000
£ 820,000
£ 830,000
£ 840,000
£ 850,000
£ 860,000
£ 870,000
£ 880,000
£ 890,000
£ 900,000
£ 910,000
£ 920,000
£ 930,000
£ 940,000
£ 950,000
£ 960,000
£ 970,000
£ 980,000
£ 990,000
£ 1,000,000
more than £ 1,000,000
Discount from council
Please choose...
£ 1,000
£ 2,000
£ 3,000
£ 4,000
£ 5,000
£ 6,000
£ 7,000
£ 8,000
£ 9,000
£ 10,000
£ 11,000
£ 12,000
£ 13,000
£ 14,000
£ 15,000
£ 16,000
£ 17,000
£ 18,000
£ 19,000
£ 20,000
£ 21,000
£ 22,000
£ 23,000
£ 24,000
£ 25,000
£ 26,000
£ 27,000
£ 28,000
£ 29,000
£ 30,000
£ 31,000
£ 32,000
£ 33,000
£ 34,000
£ 35,000
£ 36,000
£ 37,000
£ 38,000
£ 39,000
£ 40,000
£ 41,000
£ 42,000
£ 43,000
£ 44,000
£ 45,000
£ 46,000
£ 47,000
£ 48,000
£ 49,000
£ 50,000
£ 51,000
£ 52,000
£ 53,000
£ 54,000
£ 55,000
£ 56,000
£ 57,000
£ 58,000
£ 59,000
£ 60,000
£ 61,000
£ 62,000
£ 63,000
£ 64,000
£ 65,000
£ 66,000
£ 67,000
£ 68,000
£ 69,000
£ 70,000
£ 71,000
£ 72,000
£ 73,000
£ 74,000
£ 75,000
£ 76,000
£ 77,000
£ 78,000
£ 79,000
£ 80,000
£ 81,000
£ 82,000
£ 83,000
£ 84,000
£ 85,000
£ 86,000
£ 87,000
£ 88,000
£ 89,000
£ 90,000
£ 91,000
£ 92,000
£ 93,000
£ 94,000
£ 95,000
£ 96,000
£ 97,000
£ 98,000
£ 99,000
£ 100,000 or more
How long have you owned
your home?
Please choose...
more than 3 years
less than 3 years
Previous address
4. Your mortgage
Mortgage company
Outstanding balance
Please choose...
£0 – Own home outright
£5,000
£10,000
£15,000
£20,000
£25,000
£30,000
£35,000
£40,000
£45,000
£50,000
£55,000
£60,000
£65,000
£70,000
£75,000
£80,000
£85,000
£90,000
£95,000
£100,000
£110,000
£120,000
£130,000
£140,000
£150,000
£160,000
£170,000
£180,000
£190,000
£200,000
£210,000
£220,000
£230,000
£240,000
£250,000
£260,000
£270,000
£280,000
£290,000
£300,000
£310,000
£320,000
£330,000
£340,000
£350,000
£360,000
£370,000
£380,000
£390,000
£400,000
£410,000
£420,000
£430,000
£440,000
£450,000
£460,000
£470,000
£480,000
£490,000
£500,000
£510,000
£520,000
£530,000
£540,000
£550,000
£560,000
£570,000
£580,000
£590,000
£600,000
£610,000
£620,000
£630,000
£640,000
£650,000
£660,000
£670,000
£680,000
£690,000
£700,000
£710,000
£720,000
£730,000
£740,000
£750,000
£760,000
£770,000
£780,000
£790,000
£800,000
£810,000
£820,000
£830,000
£840,000
£850,000
£860,000
£870,000
£880,000
£890,000
£900,000
£910,000
£920,000
£930,000
£940,000
£950,000
£960,000
£970,000
£980,000
£990,000
£1,000,000
£1,000,000+
Monthly repayments
Please choose...
£ 0
£ 100
£ 200
£ 300
£ 400
£ 500
£ 600
£ 700
£ 800
£ 900
£ 1,000
£ 1,100
£ 1,200
£ 1,300
£ 1,400
£ 1,500
£ 1,600
£ 1,700
£ 1,800
£ 1,900
£ 2,000
£ 2,100
£ 2,200
£ 2,300
£ 2,400
£ 2,500
£ 2,600
£ 2,700
£ 2,800
£ 2,900
£ 3,000
£ 3,100
£ 3,200
£ 3,300
£ 3,400
£ 3,500
£ 3,600
£ 3,700
£ 3,800
£ 3,900
£ 4,000
£ 4,100
£ 4,200
£ 4,300
£ 4,400
£ 4,500
£ 4,600
£ 4,700
£ 4,800
£ 4,900
£ 5,000
£ 5,100
£ 5,200
£ 5,300
£ 5,400
£ 5,500
£ 5,600
£ 5,700
£ 5,800
£ 5,900
£ 6,000
£ 6,100
£ 6,200
£ 6,300
£ 6,400
£ 6,500
£ 6,600
£ 6,700
£ 6,800
£ 6,900
£ 7,000
£ 7,100
£ 7,200
£ 7,300
£ 7,400
£ 7,500
£ 7,600
£ 7,700
£ 7,800
£ 7,900
£ 8,000
£ 8,100
£ 8,200
£ 8,300
£ 8,400
£ 8,500
£ 8,600
£ 8,700
£ 8,800
£ 8,900
£ 9,000
£ 9,100
£ 9,200
£ 9,300
£ 9,400
£ 9,500
£ 9,600
£ 9,700
£ 9,800
£ 9,900
£ 10,000
more than £ 10,000
Years remaining
Please choose...
less than a year
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
10 years
15 years
20 years
25 years
30 years
40 years
50 years
Mortgage type
Please choose...
Deferred
Endowment
Flexible
Interest only
Isa
Low start
Pension
Repayment
Have you had a previous
mortgage?
No
Yes
Arrears in the last 12 months?
No
Yes
Present arrears on your
mortgage
Highest arrears have been
in the last 12 months
Last 3 repayments made
on time?
Yes
No
Any other loans secured
against your home?
No
Yes
Loan company
Total amount owed
Please choose...
less than £2,500
£2,500
£5,000
£7,500
£10,000
£15,000
£20,000
£25,000
£30,000
£35,000
£40,000
£45,000
£50,000
£55,000
£60,000
£65,000
£70,000
£75,000
£80,000
£85,000
£90,000
£95,000
£100,000
£110,000
£120,000
£130,000
£140,000
£150,000
£160,000
£170,000
£180,000
£190,000
£200,000
£210,000
£220,000
£230,000
£240,000
£250,000
£260,000
£270,000
£280,000
£290,000
£300,000
£310,000
£320,000
£330,000
£340,000
£350,000
£360,000
£370,000
£380,000
£390,000
£400,000
£410,000
£420,000
£430,000
£440,000
£450,000
£460,000
£470,000
£480,000
£490,000
£500,000
£510,000
£520,000
£530,000
£540,000
£550,000
£560,000
£570,000
£580,000
£590,000
£600,000
£610,000
£620,000
£630,000
£640,000
£650,000
£660,000
£670,000
£680,000
£690,000
£700,000
£710,000
£720,000
£730,000
£740,000
£750,000
£760,000
£770,000
£780,000
£790,000
£800,000
£810,000
£820,000
£830,000
£840,000
£850,000
£860,000
£870,000
£880,000
£890,000
£900,000
£910,000
£920,000
£930,000
£940,000
£950,000
£960,000
£970,000
£980,000
£990,000
£1,000,000
$1,000,000+
5. Your Partner
Your partner’s name
Mr.
Mrs.
Miss.
Ms.
Dr.
Hon.
Rev.
Your partner’s maiden name
Date of birth
dd
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
mm
01
02
03
04
05
06
07
08
09
10
11
12
yyyy
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
Annual income (before tax)
Please choose...
0
£ 1,000
£ 2,000
£ 3,000
£ 4,000
£ 5,000
£ 6,000
£ 7,000
£ 8,000
£ 9,000
£ 10,000
£ 11,000
£ 12,000
£ 13,000
£ 14,000
£ 15,000
£ 16,000
£ 17,000
£ 18,000
£ 19,000
£ 20,000
£ 21,000
£ 22,000
£ 23,000
£ 24,000
£ 25,000
£ 26,000
£ 27,000
£ 28,000
£ 29,000
£ 30,000
£ 31,000
£ 32,000
£ 33,000
£ 34,000
£ 35,000
£ 36,000
£ 37,000
£ 38,000
£ 39,000
£ 40,000
£ 41,000
£ 42,000
£ 43,000
£ 44,000
£ 45,000
£ 46,000
£ 47,000
£ 48,000
£ 49,000
£ 50,000
£ 51,000
£ 52,000
£ 53,000
£ 54,000
£ 55,000
£ 56,000
£ 57,000
£ 58,000
£ 59,000
£ 60,000
£ 61,000
£ 62,000
£ 63,000
£ 64,000
£ 65,000
£ 66,000
£ 67,000
£ 68,000
£ 69,000
£ 70,000
£ 71,000
£ 72,000
£ 73,000
£ 74,000
£ 75,000
£ 76,000
£ 77,000
£ 78,000
£ 79,000
£ 80,000
£ 81,000
£ 82,000
£ 83,000
£ 84,000
£ 85,000
£ 86,000
£ 87,000
£ 88,000
£ 89,000
£ 90,000
£ 91,000
£ 92,000
£ 93,000
£ 94,000
£ 95,000
£ 96,000
£ 97,000
£ 98,000
£ 99,000
£ 100,000
£ 110,000
£ 120,000
£ 130,000
£ 140,000
£ 150,000
£ 160,000
£ 170,000
£ 180,000
£ 190,000
£ 200,000
more than £ 200,000
Time in present job
Please choose...
less than a year
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
10 years
15 years
20 years
25 years
30 years
40 years
50 years
Phone number
Same address as you?
No
Yes
Partner’s address
Finish
I have read and agree to the
declaration
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