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Financial connections questionnaire/disassociation form

Please answer the following questions so that we can consider your request to remove your financial link (association to) another person. This process is called disassociation. A separate form should be completed for each person from whom you wish to disassociate.

Report reference number:

STEP ONE — Please complete the following details about you

E-mail address
Confirm e-mail address

Surname

Full Forename

Middle Name

Title
Any other names that you have been known by:
Date of birth
Present address
Town
County
Postcode
How long have you lived at this address:
Your previous addresses in the last 6 years
Address one
Address two
Address three
Address four
How many people do you want to remove from you credit report?

STEP TWO — Please complete the following details about the person from whom you wish to disassociate

Person one
What is this person's relationship to you?:
Surname
Full Forename
Middle Name
Title
Date of birth
Any other names that this person has been known by:
Their present address:
Town
County
How long have they lived at this address:
Please provide all the addresses that you have shared with this person in the last 6 years:
Address one
Address two
Address three
Address four

STEP THREE — Please complete

Do you and the person referred to share any joint credit agreements, for example joint credit card or mortgage? (This also includes joint bank accounts) Yes No
Do you have any other shared financial link? Yes No
If any joint applications were made recently (within the last year) did you open an account which is still open? Yes No
If you have previously told Experian that you are financially connected, are you still financially connected? Yes No
If you LIVE at the same address tick the box to indicate that you keep your finances seperate.
If you have ticked YES to any questions above please explain why you believe you should no longer be considered as being financially linked so that we can assess your circumstances fully:

I confirm that there is no active financial connection or dependency between myself and the person detailed above.

I confirm that the information provided on this form is correct and I understand that failure to complete this form or any attempt to misrepresent information, may result in the request being refused.

I understand that if I make a false statement and, as a result, obtain finance that I might not otherwise have obtained, I may be guilty of a criminal offence.

I also understand that Experian may verify the details I have given against their own records and, in some cases, may need to request further information in support of this application.