Rent Arrears Repayment Offer

Your details: Name: Address: Town: Post Code: Telephone: Email: About your arrears I offer to pay an extra £ each week on top of my rent. I would like to talk to someone about my arrears. Personal Information We are working towards a policy of ensuring that we provide services fairly whatever a person's age, disability, race, colour or ethnic origin. Please give the following information. We'll use it to check that all our customers receive a fair service. All the information you provide will be held in confidence. It will not be released to others without your written agreement. Your gender Male Female Disability Do you have a physical disability? Yes No Your age 16-25 26-40 41-59 60-74 75 or over Your ethnic origin White White British White Irish White other Asian or Asian British Indian Pakistani Bangladeshi Asian other Black or Black British Caribbean African Black other Mixed White & Black Caribbean White & Black African White & Asian Other mixed Other ethnic group Chinese Any other ethnic group