FORM 16 - APPLICATION FOR DEBT REVIEW in terms of S 86 OF THE NATIONAL CREDIT ACT, 34 of 2005

Transcription

1 Cell: * Fax: * dc@zunecoetzer.co.za * Web: * Skype: zune.coetzer * PO Box 42669, Heuwelsig, 9332 *NCRDC1599 FORM 16 - APPLICATION FOR DEBT REVIEW in terms of S 86 OF THE NATIONAL CREDIT ACT, 34 of 2005 FOR OFFICE USE ONLY Office file nr: Legal File nr: 30 Days 1 st Pmnt date: Debt Repayment: R 60 Days Please take note: 1. Completing this form does not constitute being under debt review. Only after you have signed the mandate and the debt counsellor have accepted the application, will you be formally under debt review. 2. The debt counsellor will do a preliminary evaluation of your financial position and should it seem that you are over indebted, a formal appointment at our office will be arranged. This appointment is a free consultation where after you can decide if you want to proceed or not. 3. The lists of documents are a generic list. Please provide our office with as much documentation as possible so that we can be of assistance to you. 4. Take note that the debt counsellor (NCRDC1599) strictly adheres to the prescriptions of the National Credit Act, 34 of 2005 and your evaluation, the debt review process and subsequent referral to court will be done in line with S86 of the NCA read with: S78, S79, S88(1), S113, S125, R24 and the Debt Counselling Regulations Please attach the relevant documentation to this application Copy of ID documents for applicant Copy of Marriage Certificate / Decree of Divorce / Death Certificate / Marriage contract if married ICP Copy of Birth Certificates / ID documents of dependents Proof of residential address and or rental contract Proof of water and electricity and or levies and or rates and taxes Last 2 months Salary Advice Last 2 months bank statements Proof of Telkom / Cell phone / Internet expenses Proof of school fees and all related expenses Proof of Short term insurance (especially on vehicles) Proof of life policies if not shown on salary advice Proof of medical aid if not shown on salary advice Poof of any alternative expenses shown on your budget Proof of all the debt (incl a current credit check)

2 APPLICATION DETAILS Application type: New Transfer Previous DC Info: DC Name NCRDC nr Where did you hear of us: Friend Internet Facebook Psychologist Yellow Pages Other Reason for Application: Attach additional documentation if needed PART 1 : PERSONAL DETAILS Details Primary Applicant Surname: Full names: Nick name: Identity Nr: Gender: Race: Relationship Status: Single Divorced Widow(er) Married (COP) Names Age Sex 1. Dependents: Married out of Physical Address: Postal address: Cell nr: Address: Name of Employer: Job description: Postal Code Fax nr: Period Employed Tel nr (work): Address of Employer: Salary date: 1 st 15 th 25 th 30/31 Other I consent to service of the court application via: Via Via fax By hand

3 List of assets: ASSET 1. R 2. R 3. R 4. R 5. R ESTIMATED VALUE Details PART 2 : INCOME Gross Income: R LESS Deductions on pays lip -R Total =R PLUS Other income +R Total income =R Rent Rates & Taxes PART 3 : MONTHLY COMMITMENTS (NB ONLY LIVING EXPENSES, EXCLUDING DEBT REPAYMENTS) Commitment Monthly Expenses Debt Counselor s Suggestion Water & Electricity Transport (Taxi fare/petrol) Groceries Communication (Cellphones + land lines) Internet School fees Clothing for household Medical All Policies Insurance Maintenance Other: TOTAL R R

4 ACCOUNT TYPE CREDIT PROVIDER PART 4 : DEBT OBLIGATIONS ACC NR (if proof is not attached) TOTAL AMOUNT OWING MONTHLY PAYMENT Overdraft Bank X TOTAL DEBT AND REPAYMENT PER MONTH R R DETERMINATION OF OVER-INDEBTEDNESS ITO REG 24(7) Gross income R Less statutory deductions - R Netto income = R Plus additional income + R LESS Living Expenses - R AVAILABLE FUNDS FOR DISTRIBUTION = R LESS Total Debt Repayment - R Consumer(s) over indebted with = R

5 POWER OF ATTORNEY I, the undersigned: APPLICANT: NAME: I.D.: Do hereby nominate, constitute and appoint Zuné Coetzer NCRDC1599 ID Number or any person who has been appointed by her to assist her in her debt counselling duties; To do for me, and on my behalf, make enquiries at any / every credit bureau or financial institution in order to ascertain my credit status and counsel me in regard to debt relief and prepare a responsible debt repayment plan for the court. This authority extends to all / any / every one of my creditors, and to do all such things and act in all circumstances as if I were personally present and acting therein including: Requesting a settlement statement in terms of S113 of the NCA, 34 of 2005; To utilize a payment switch registered with PASA, appointed by myself; Signed at (place)....on. (day) of.. (month) 20. Signature Applicant: Full name & Surname:.