Obligation-Free Quote

Form 16

Part 1 - Personal Details

Note: Your privacy is very important to us. To better serve you, the form information you enter is recorded in real time.

Name*

First Name

Last Name

ID Number*

I herewith consent to service of my Debt Review Application and/or all other court document relating to the said debt review application on me by email at:

Email*

Phone (Cell)

Phone (Home)

Gender

Male Female

Ethnic Group

African Coloured Indian White Other

Marital Status

Language Preference

Number of Dependants

Ages of Dependants

Please separate ages with a comma (,)

Where do your school-going children stay after school?

Answer if applicable only

Physical Address

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Postal Address

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Employer

Job Title

Phone (Work)

Employer Address

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Part 2 - Spouse Details (Compulsory if married in COP or African Traditional)

Spouse Full Name

First Name

Last Name

Spouse ID Number

Spouse Phone (Work)

Spouse Phone (Cell)

Spouse Employer Name

Spouse Employer Address

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Part 3 - Budget Details

A. Income

Gross Income - Main Applicant

Gross Income - Spouse

Commission - Main Applicant

(6 month average)

Commission - Spouse

(6 month average)

Overtime - Main Applicant

(6 month average)

Overtime - Spouse

(6 month average)

Rental Income - Main Applicant

Rental Income - Spouse

Child Maintenance Income - Main Applicant

Child Maintenance Income - Spouse

Total Income - Main Applicant

Total Income - Spouse

B. Salary Deductions

PAYE - Main Applicant

PAYE - Spouse

UIF - Main Applicant

UIF - Spouse

Pension/Provident Fund - Main Applicant

Pension/Provident Fund - Spouse

Medical Aid - Main Applicant

Medical Aid - Spouse

Garnishee Orders - Main Applicant

Garnishee Orders - Spouse

Staff Loans - Main Applicant

Staff Loans - Spouse

Other - Main Applicant

Other - Spouse

Total Deductions - Main Applicant

Total Deductions - Spouse

Nett Salary (A - B) - Main Applicant

Nett Salary (A - B) - Spouse

C. Living Expenses

Food / Groceries / Clothing - Main Applicant

Food / Groceries / Clothing - Spouse

Property Rental - Main Applicant

Property Rental - Spouse

Water / Electricity / Rates / Levies - Main Applicant

Water / Electricity / Rates / Levies - Spouse

Security - Main Applicant

Security - Spouse

School Fees - Main Applicant

School Fees - Spouse

Short Term Insurance - Main Applicant

Short Term Insurance - Spouse

Vehicle Insurance - Main Applicant

Vehicle Insurance - Spouse

Life Insurance - Main Applicant

Life Insurance - Spouse

Fuel/Transport - Main Applicant

Fuel/Transport - Spouse

Child Maintenance - Main Applicant

Child Maintenance - Spouse

Medical Costs - Main Applicant

Medical Costs - Spouse

Telephone & Internet - Main Applicant

Telephone & Internet - Spouse

Other - Main Applicant

Please specify

Other - Spouse

Please specify

Total Expenses - Main Applicant

Total Expenses - Spouse

Amount Available For Debt Review - Main Applicant

(Nett Salary - C)

Amount Available For Debt Review - Spouse

(Nett Salary - C)

Part 4 – If Married Out of Community of Property (Antenuptial Contract) and Single Application, please complete the following

Is your spouse employed?

If employed, what amount does your spouse contribute to the monthly expenses?

Part 5 – Creditor Obligations (please list bank overdrafts if applicable)

Please note that all other creditor information will be obtained from the credit report.

Creditor & Account Type

Account Number

Outstanding Balance

Current Instalment

Creditor #2 & Account Type

Account Number #2

Outstanding Balance #2

Current Instalment #2

Creditor #3 & Account Type

Account Number #3

Outstanding Balance #3

Current Instalment #3

Creditor #4 & Account Type

Account Number #4

Outstanding Balance #4

Current Instalment #4

Creditor #5 & Account Type

Account Number #5

Outstanding Balance #5

Current Instalment #5

Creditor #6 & Account Type

Account Number #6

Outstanding Balance #6

Current Instalment #6

Part 6 – Previous Debt Review Information

Have you previously been under debt review?

If yes, please give details of the previous debt counsellor

Reason for leaving previous debt counsellor

Was a court order granted?

Part 7 – Reason for Over Indebtedness

Please provide a short description of the reason for over indebtedness

Declaration

I hereby declare that the information supplied by myself in the application form is for myself and is true and correct. I consent to Debt Rescue obtaining my credit report from a registered credit bureau for the purpose of obtaining my credit agreements to assist in the assessment.*

Agree Disagree

Copy of ID - Main Applicant

No File Chosen

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Copy of ID - Spouse (If Married in Community of Property)

No File Chosen

File uploads may not work on some mobile devices.

Copy of latest Payslip

No File Chosen

File uploads may not work on some mobile devices.

Copy of latest Payslip - Spouse (If Applicable)

No File Chosen

File uploads may not work on some mobile devices.

Signature

[clear]

Use your mouse or finger to draw your signature above

Signature - Spouse

[clear]

Use your mouse or finger to draw your signature above

Campaign Source

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Campaign Medium

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Campaign Term

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Campaign Name

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GCLID (Google Click Identifier)

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Click ID

Campaign Content

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