Print form Reset form

Admission (specified amount) Name of court

Print form
• You have a limited number of days to complete and
return this form Claim No.
• Before completing this form, please read the notes
for guidance attached to the claim form Claimant
(including ref.)

When to fill in this form

• You are admitting all of the claim and you are asking for Defendant
time to pay; or
• You are admitting part of the claim. (You should also
complete form N9B).
2 Dependants (people you look after financially)
How to fill in this form
Number of children in each age group
Individual
• Tick the correct boxes and give as much information under 11 11-15 16-17 18 & over
as you can. Then sign and date the form. If necessary
provide details on a separate sheet add the claim number
and attach it to this form. Other dependants
(give details)
• Make your offer of payment in box 11 on the back of this
form. If you make no offer the claimant will decide how
much and when you should pay. 3 Employment
Organisation I am employed as a
• If you are not an individual, you should ensure you attach
a financial statement showing your companies profit, My employer is
loss, assets and liabilities to support any offer of payment
made in box 11. Ensure you tick the correct box and Jobs other than main
complete sections 1, 9 (if applicable) and 12. If you are a job (give details)
Limited Company, the claimant is under no obligation to
accept your offer. I am self employed as a
• You can get help to complete this form at any County
Court or Citizen Advice Bureau. Annual turnover is £

Where to send this form I am not in arrears with my national insurance

• If you admit the claim in full contributions, income tax and VAT
Send the completed form to the claimants address shown
on the claim form as one to which documents should be sent. I am in arrears and I owe £
• If you admit only part of the claim Give details of:
Send the form to the issuing court at the address given
(a) contracts and
on the claim form, together with the defence form (N9B).
other work in hand
How much of the claim do you admit?
(b) any sums due
I admit the full amount claimed as shown on for work done
the claim form or
I admit the amount of £ I have been
unemployed for years months
1 Personal/Organisation details I am a pensioner
Surname/
Organisation 4 Bank account and savings
I have a bank account
Forename
The account is in credit by £
Mr Mrs Miss Ms
The account is overdrawn by £
Married Single Other
(specify) I have a savings or building society account
The amount in the account is £
Date of birth D D M M Y Y Y Y

Address 5 Residence
I live in my own house lodgings
my jointly council
owned house accommodation
Phone no. rented accommodation
N9A Form of admission (specified amount) (04.14) © Crown copyright 2014
6 Income 8 Priority debts
(This section is for arrears only. Do not include regular expenses listed in box 7.)
My usual take home pay (including
£ per Rent arrears £ per
overtime, commission, bonuses etc.)
Income support £ per Mortgage arrears £ per
Child benefit(s) £ per Council tax/Community Charge
£ per
arrears
Other state benefit(s) £ per
Water charges arrears £ per
My pension(s) £ per
Fuel debts: Gas £ per
Others living in my home give me £ per
Electricity £ per
Other income (give details below)
Other £ per
£ per
Maintenance arrears £ per
£ per
Others (give details below)
£ per
£ per
Total income £ per
£ per
Total priority debts £ per
7 Expenses
(Do not include any payments made by
other members of the household out of their own income)
9 Court orders
I have regular expenses as follows: Court Claim No. £ per
£ per
Mortgage (including second mortgage) £ per
£ per
Rent £ per
£ per
Council tax £ per Total court order instalments £ per
Gas £ per
Of the payments above, I am behind with payments to (please list)
Electricity £ per
Water charges £ per

TV rental and licence £ per

10 Credit debts
HP repayments £ per Loans and credit card debts (please list)
Mail order £ per £ per
£ per
Housekeeping, food, school meals £ per £ per
Travelling expenses £ per Of the payments above, I am behind with payments to (please list)
Children’s clothing £ per
Maintenance payments £ per
Others (not court orders or credit debts
listed in boxes 9 and 10)
11 Offer of payment
£ per
I can pay the amount admitted on
£ per or
£ per I can pay by monthly instalments of £

Total expenses £ per If you cannot pay immediately, please give brief reasons below

12 Declaration I declare that the details I have given above are true to the best of my knowledge
Signed Position or office held
(if signing on behalf of firm
or company) Reset form

Date Print form Reset form