Payment Arrears Assessment Form
Use this form to assess overdue payment status, understand the cause of arrears, and determine next steps for resolution.
Account and Arrears Details
Account reference or case reference
*
Account holder name or organization name
*
Best contact method
*
Phone
Email
SMS
Postal mail
Current arrears amount range
*
Under 100
100–499
500–999
1000+
Payment cycles overdue
*
Assessment of Payment Situation
Payment History
*
Willingness to Resolve Arrears
*
Very unwilling
1
2
3
4
5
6
7
8
9
Very willing
10
1 is Very unwilling, 10 is Very willing
Main Reason for Arrears
*
Temporary cash flow issue
Loss of income
Billing dispute
Forgotten payment
Other
Urgency of Follow-up Needed
*
1
2
3
4
5
Resolution and Next Steps
Preferred repayment option
*
Pay in full
Partial payment
Installment plan
Need a callback
Expected date for next payment
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional notes or supporting details
Submit
Should be Empty: