When to ll in this form
You are admitting all of the claim and you are asking for
time to pay; or
You are admitting part of the claim. (You should also
complete form N9B).
How to ll in this form
Tick the correct boxes and give as much information
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.
Make your oer of payment in box 11 on the back of this
form. If you make no oer the claimant will decide how
much and when you should pay.
If you are not an individual, you should ensure you attach
a nancial statement showing your companies prot,
loss, assets and liabilities to support any oer of payment
made in box 11. Ensure you tick the correct box and
complete sections 1, 9 (if applicable) and 12. If you are a
Limited Company, the claimant is under no obligation to
accept your oer.
You can get help to complete this form at any County
Court or Citizen Advice Bureau.
Where to send this form
If you admit the claim in full
Send the completed form to the claimants address shown
on the claim form as one to which documents should be sent.
If you admit only part of the claim
Send the form to the issuing court at the address given
on 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 on
the claim form
I admit the amount of £
1 Personal/Organisation details
Mr Mrs Miss Ms
Married Single
Date of birth
Phone no.
2 Dependants (people you look after nancially)
Number of children in each age group
under 11 11-15 16-17 18 & over
Other dependants
(give details)
N9A Form of admission (specied amount) (04.14) © Crown copyright 2014
Admission (specied amount)
You have a limited number of days to complete and
return this form
Before completing this form, please read the notes
for guidance attached to the claim form
Name of court
Claim No.
(including ref.)
5 Residence
I live in
my own house lodgings
my jointly
owned house
rented accommodation
4 Bank account and savings
I have a bank account
The account is in credit by £
The account is overdrawn by £
I have a savings or building society account
The amount in the account is £
3 Employment
I am employed as a
My employer is
Jobs other than main
(give details)
I am self employed as a
Annual turnover is £
I am not in arrears with my national insurance
contributions, income tax and VAT
I am in arrears and I owe £
Give details of:
(a) contracts and
other work in hand
(b) any sums due
for work done
I have been
unemployed for
years months
I am a pensioner
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9 Court orders
Court Claim No.
£ per
£ per
£ per
£ per
Total court order instalments £ per
Of the payments above, I am behind with payments to
(please list)
8 Priority debts
(This section is for arrears only. Do not include regular expenses listed in box 7.)
Rent arrears £ per
Mortgage arrears £ per
Council tax/Community Charge
£ per
Water charges arrears £ per
Fuel debts: Gas £ per
Electricity £ per
Other £ per
Maintenance arrears £ per
(give details below)
£ per
£ per
Total priority debts £ per
6 Income
My usual take home pay (including
overtime, commission, bonuses etc.)
£ per
Income support £ per
Child benet(s) £ per
Other state benet(s) £ per
My pension(s) £ per
Others living in my home give me £ per
Other income
(give details below)
£ per
£ per
£ per
Total income
£ per
7 Expenses
(Do not include any payments made by
other members of the household out of their own income)
I have regular expenses as follows:
Mortgage (including second mortgage)
£ per
£ per
Council tax
£ per
£ per
£ per
Water charges
£ per
TV rental and licence
£ per
HP repayments
£ per
Mail order
£ per
Housekeeping, food, school meals
£ per
Travelling expenses
£ per
Childrens clothing
£ per
Maintenance payments
£ per
(not court orders or credit debts
listed in boxes 9 and 10)
£ per
£ per
£ per
Total expenses £ per
10 Credit debts
Loans and credit card debts (please list)
£ per
£ per
£ per
Of the payments above, I am behind with payments to
(please list)
11 Oer of payment
I can pay the amount admitted on
I can pay by monthly instalments of £
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 oce held
(if signing on behalf of rm
or company)
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