Name *

First Name

Last Name

Reason for Requesting Payment Assistance *

You are ill, or have been ill (recently)

Someone in your household is ill or has been ill

An unexpected event or unforeseen change has reduced your income

An unexpected event or unforeseen change has increased your expenditure

There has been a change in your personal circumstances

There has been a change in your family circumstances

There is, or has been, a natural disaster

Other

Options *

Option 1 - I wish to change the date my next installment

Option 2 - I would like to make a change to my regular direct debit payment dates

Option 3 - I wish to change my regular direct debit frequency

Option 4 - I would like to reduce my agreed direct debit installments by up to 50% for a period not exceeding three months