PERSONAL INFORMATION-APPLICANT: |
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Full Names: |
Marital Status: |
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Surname: |
How Married: (Community of property/Anti Nuptial Contract/Traditional) |
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Maiden Name: |
Date:(divorced/separated): |
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ID Number: |
Race: |
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email: |
Tel (House) |
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Cell Nr.: |
Tel (Work) |
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Residential Address:(Owner/Tennant) |
Postal Address: |
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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? |
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Name |
Age |
Gender |
Relationship |
Details |
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SPOUSE'S INFO: |
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Full Names: |
email: |
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Surname: |
Cell Nr: |
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Maiden Name: |
Tel (House) |
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ID Number: |
Tel (Work) |
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NEXT OF KIN/FRIEND |
NEXT OF KIN/FRIEND |
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Names: |
Names: |
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Relationship: |
Relationship: |
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Cell Nr: |
Cell Nr: |
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Tel (Work): |
Tel (Work): |
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NEXT OF KIN/FRIEND |
NEXT OF KIN/FRIEND |
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Names: |
Names: |
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Relationship: |
Relationship: |
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Cell Nr: |
Cell Nr: |
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Tel (Work) |
Tel (Work) |
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APPLICANTS EMPLOYMENT: |
SPOUSE'S EMPLOYMENT: |
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Employer: |
Employer: |
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Name of School/Hospital/Station: |
Name of School/Hospital/Station: |
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Occupation: |
Since: |
Occupation: |
Since: |
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Tel No: |
Employee No: |
Tel No: |
Persal No: |
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INCOME:-PLEASE NOTE: PROOF OF INCOME & EXPENSES IS REQUIRED a week before COURT date!!! |
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Salary |
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Food |
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Pension Income |
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Rent/Bond |
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SPOUSE Income |
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Water & ELECT |
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Child Maintenance |
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rates & taxes |
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CHILD/DISABILITY GRANTS |
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Transport |
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Telephone |
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Licenses(Car/SABC TV) |
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TOTAL INCOME= |
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Medical Expenses |
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EXPENSES: |
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Life/Funeral Insurance Policies(not on payslip) |
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School Fees |
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Car Insurance |
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School transport |
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Medical Aid/HOSPITAL plan(not on payslip) |
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University/College/Tech fees |
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Furniture/Car (HP Agreements/Leases) |
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Hostel fees |
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Child Maintenance |
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AFTERCARE/DAY MOTHER |
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TOTAL EXPENSES= |
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DEBT OBLIGATIONS:-ALL Credit CARDS/Clothing CARDS to be handed in and NOT USED AGAIN!! |
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COMPANY: |
REF/ACCOUNT NO: |
instalment |
BALANCE |
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2) |
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3) |
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4) |
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14) |
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15) |
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16) |
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17) |
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DECLARATION BY APPLICANT |
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I declare as follows: |
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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; |
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2. I hereby consent to the submission of my information to all registered credit bureaus by the debt counsellor; |
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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; |
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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: |
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a. The debt counsellor/administrator rejects my application; |
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b. The court determines that I am not over-indebted; or |
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c. All my obligations under credit agreements as re-arranged are fulfilled |
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5. I confirm that the information contained in this document is, to the best of my knowledge, true and correct. |
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Signed at __________________________________________ on this ________ of _______________________________ 20 ________ |
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Signature: _________________________________ |
SPOUSE: |
_____________________________________ |
Application for DEBT REVIEW