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PERSONAL INFORMATION-APPLICANT:

Full Names:

Marital Status:

Surname:

How Married: (Community of property/Anti Nuptial Contract/Traditional)

Maiden Name:

Date:(divorced/separated):

ID Number:

Race: 

email:

Tel (House)

Cell Nr.:

Tel (Work)

Residential Address:(Owner/Tennant)

Postal Address:

 

 

 

 

No of dependants: LIST only OWN biological children scholars/student with proof of studies (under 21)

Provide BIRTH CERTIFICATES for ALL and REASON why you are responsible for dependant/s not your own?

Name

Age

Gender

Relationship

Details

1)

 

 

 

 

2)

 

 

 

 

3)

 

 

 

 

4)

 

 

 

 

5)

 

 

 

 

6)

 

 

 

 

7)

 

 

 

 

8)

 

 

 

 

SPOUSE'S INFO:

Full Names:

email:

Surname:

Cell Nr:

Maiden Name:

Tel (House)

ID Number:

Tel (Work)

NEXT OF KIN/FRIEND

NEXT OF KIN/FRIEND

Names:

Names:

Relationship:

Relationship:

Cell Nr:

Cell Nr:

Tel (Work):

Tel (Work):

NEXT OF KIN/FRIEND

NEXT OF KIN/FRIEND

Names:

Names:

Relationship:

Relationship:

Cell Nr:

Cell Nr:

Tel (Work)

Tel (Work)

APPLICANTS EMPLOYMENT:

SPOUSE'S EMPLOYMENT:

Employer:

Employer:

Name of School/Hospital/Station:

Name of School/Hospital/Station:

Occupation:

Since:

Occupation:

Since:

Tel No:

Employee No:

Tel No:

Persal No:

INCOME:-PLEASE NOTE: PROOF OF INCOME & EXPENSES IS REQUIRED a week before COURT date!!!

Salary

 

Food

 

Pension Income

 

Rent/Bond

 

SPOUSE Income

 

Water & ELECT

 

Child Maintenance

 

rates & taxes

 

CHILD/DISABILITY GRANTS

 

Transport

 

 

 

Telephone

 

 

 

Licenses(Car/SABC TV)

 

TOTAL INCOME=

 

Medical Expenses

 

EXPENSES:

 

Life/Funeral Insurance Policies(not on payslip)

 

School Fees

 

Car Insurance

 

School transport

 

Medical Aid/HOSPITAL plan(not on payslip)

 

University/College/Tech fees

 

Furniture/Car (HP Agreements/Leases)

 

Hostel fees

 

 

 

Child Maintenance

 

 

 

AFTERCARE/DAY MOTHER

 

TOTAL EXPENSES=

 

DEBT OBLIGATIONS:-ALL Credit CARDS/Clothing CARDS to be handed in and NOT USED AGAIN!!

COMPANY:

REF/ACCOUNT NO:

instalment

BALANCE

1)

 

 

 

2)

 

 

 

3)

 

 

 

4)

 

 

 

5)

 

 

 

6)

 

 

 

7)

 

 

 

8)

 

 

 

9)

 

 

 

10)

 

 

 

11)

 

 

 

12)

 

 

 

13)

 

 

 

14)

 

 

 

15)

 

 

 

16)

 

 

 

17)

 

 

 

DECLARATION BY APPLICANT

I declare as follows:

 

 

 

1.  I undertake to comply with all requests from the debt counsellor/administrator to assist him/her to evaluate my state of indebtedness and the prospects for responsible debt restructuring;

2. I hereby consent to the submission of my information to all registered credit bureaus by the debt counsellor;

3. I also consent that the debt counsellor/ administrator may obtain my credit record from any/all registered credit bureaus and any other registers which may contain any of my credit information;

4. I undertake not to enter into any further credit agreements, other than a consolidated agreement, with any credit provider until one of the following events has occurred:

a. The debt counsellor/administrator rejects my application;

b. The court determines that I am not over-indebted; or

c. All my obligations under credit agreements as re-arranged are fulfilled

5. I confirm that the information contained in this document is, to the best of my knowledge, true and correct.

Signed at __________________________________________ on this ________ of _______________________________ 20 ________

 

 

 

 

Signature: _________________________________

SPOUSE:

_____________________________________