Please enable JavaScript in your browser to complete this form.NameMiss.Miss.Mr.Mrs.Ms.Dr.Prof.Rev.FirstLastAddress *Address Line 1Address Line 2CityState / Province / RegionPostal CodePhoneEmailPlease provide a telephone number or email address so that we can contact you.Have you contacted us before?YesNoI'm requesting advice about *Not being able to pay my water billMultiple debtsOtherHow did the issue arise? *What action have you taken so far? *What would you like us to do for you? *What extra financial issues might you be facing?Rent arrearsCredit card debtCouncil tax arrearsIs there a deadline you need to meet?DateHow would you describe yourself?White – BritishWhite – ScottishWhite – WelshWhite – Norther IrishWhite – Gypsy, Roma or TravellerWhite – OtherMixed – White & Black CaribbeanMixed – White & Black AfricaMixed – White & AsianMixed – OtherAsian or Asian British – BangladeshiAsian or Asian British – ChineseAsian or Asian British – IndianAsian or Asian British – PakistaniAsian or Asian British – OtherBlack or Black British – AfricanBlack or Black British – CaribbeanBlack or Black British – OtherOther – ArabOther – Any otherUnknownPrefer not to sayDo you have any disability or health problems?Not disabled / No health problemsLong term health condition(s)DisabledUnknownPrefer not to sayData protection *I agree to Citizens Adivce – Bath & North East Somerset storing and using information about meWe keep your details on our database which is confidential to Citizens Advice. The details we take are to enable us to give you the appropriate advice. They aren’t accessed by anyone else except in the case of gathering feedback on our service which is also done confidentially. We don’t sell your data to anyone. Is that okay with you?Submit
