starred * questions are mandatory

Sundry Debtors Invoices Instalment Request

Please use this form if you have an invoice that you wish to settle by instalments.
 

Applicant details

Address in Dudley? Type in postcode and click Find Address.
Outside Borough? 
Please enter full address below.
 
Help IconPlease enter details manually if address lies outside the Dudley borough.
 
 
Contact method *
Contact method
Is the contact address different to the above? *
Is the contact address different to the above?
 
If the contact address is different to the applicant address, please enter details below.
 

Contact address

Address in Dudley? Type in postcode and click Find Address.
Outside Borough? 
Please enter full address below.
 
Help IconPlease enter details manually if address lies outside the Dudley borough.
 
 

Payment details

 
£
 
Payment start date *
Payment start date
 
£
Payment to be made *
Payment to be made
 
Would you like to add any other comments or details that may be relevant? *
Would you like to add any other comments or details that may be relevant?
 
 
We normally expect payment by instalment to be completed within 6 months except for exceptional circumstances.
 
Alternatively, if you wish to pay by Direct Debit, please tick this box and we will send a mandate to you.
 

Review & submit

Before you submit:

  • Review your completed request
  • If required, print or save this review copy for your own records, or
  • If you wish to receive an email copy of your request, ensure you have entered your email address above.
 
Yes, I wish to receive an email copy of my request.
 

Data Protection Statement

The information you provide on this form is subject to the provision of the Data Protection Act 1998. The information will be held confidentially and will be retained for the purposes of processing your request, updating relevant records and meeting our statutory obligations.

Please refer to our Privacy & Disclaimer Statement below for our Information Charter and general information on our approach to security, confidentiality, data collection, etc.

Further data protection information can be obtained from the Information Commissioner's website at www.ico.gov.uk.
 
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