N9A - Admission (specified amount)

Admission (specified amount)• You have a limited number of days to complete andreturn this form• Before completing this form, please read the notesfor guidance attached to the claim formWhen to fill in this form• You are admitting all of the claim and you are asking fortime to pay; or• You are admitting part of the claim. (You should alsocomplete form N9B).How to fill in this formIndividual• Tick the correct boxes and give as much informationas you can. Then sign and date the form. If necessaryprovide details on a separate sheet add the claim numberand attach it to this form.• Make your offer of payment in box 11 on the back of thisform. If you make no offer the claimant will decide howmuch and when you should pay.Organisation• If you are not an individual, you should ensure you attacha financial statement showing your companies profit,loss, assets and liabilities to support any offer of paymentmade in box 11. Ensure you tick the correct box andcomplete sections 1, 9 (if applicable) and 12. If you are aLimited Company, the claimant is under no obligation toaccept your offer.• You can get help to complete this form at any CountyCourt or Citizen Advice Bureau.Where to send this form• If you admit the claim in fullSend the completed form to the claimants address shownon the claim form as one to which documents should be sent.• If you admit only part of the claimSend the form to the issuing court at the address givenon the claim form, together with the defence form (N9B).How much of the claim do you admit?I admit the full amount claimed as shown onthe claim form orI admit the amount of £1 Personal/Organisation detailsSurname/OrganisationForenameMr Mrs Miss MsMarriedSingleOther(specify)Date of birth D D M M Y Y Y YAddressName of courtClaim No.Claimant(including ref.)Defendant2 Dependants (people you look after financially)Number of children in each age groupunder 11 11-15 16-17 18 & overOther dependants(give details)3 EmploymentI am employed as aMy employer isJobs other than mainjob (give details)I am self employed as aAnnual turnover is £I am not in arrears with my national insurancecontributions, income tax and VATI am in arrears and I owe £Give details of:(a) contracts andother work in hand(b) any sums duefor work doneI have beenunemployed for years monthsI am a pensioner4 Bank account and savingsI have a bank accountThe account is in credit by £The account is overdrawn by £I have a savings or building society accountThe amount in the account is £5 ResidenceI live in my own house lodgingsPhone no.my jointlyowned houserented accommodationcouncilaccommodationN9A Form of admission (specified amount) (04.14) © Crown copyright 2014

6 IncomeMy usual take home pay (includingovertime, commission, bonuses etc.)£ perIncome support £ perChild benefit(s) £ perOther state benefit(s) £ perMy pension(s) £ perOthers living in my home give me £ perOther income (give details below)£ per£ per£ perTotal income £ per7 Expenses(Do not include any payments made byother members of the household out of their own income)I have regular expenses as follows:Mortgage (including second mortgage) £ perRent £ perCouncil tax £ perGas £ perElectricity £ per8 Priority debts(This section is for arrears only. Do not include regular expenses listed in box 7.)Rent arrears £ perMortgage arrears £ perCouncil tax/Community Chargearrears£ perWater charges arrears £ perFuel debts: Gas £ perElectricity £ perOther £ perMaintenance arrears £ perOthers (give details below)9 Court orders£ per£ perTotal priority debts £ perCourt Claim No. £ per£ per£ per£ perTotal court order instalments £ perOf the payments above, I am behind with payments to (please list)Water charges £ perTV rental and licence £ perHP repayments £ perMail order £ perHousekeeping, food, school meals £ perTravelling expenses £ perChildren’s clothing £ per10 Credit debtsLoans and credit card debts (please list)£ per£ per£ perOf the payments above, I am behind with payments to (please list)Maintenance payments £ perOthers (not court orders or credit debtslisted in boxes 9 and 10)£ per£ per£ perTotal expenses £ per11 Offer of paymentI can pay the amount admitted onorI can pay by monthly instalments of £If you cannot pay immediately, please give brief reasons below12 Declaration I declare that the details I have given above are true to the best of my knowledgeSignedPosition or office held(if signing on behalf of firmor company)Date