Obligation Free Quote - Debt Warriors

Part 1 - Personal Details

Name* First Name

Surname* 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 MaleFemale

Ethnic Group*

Marital Status*

Language Preference

Number of Dependants

Ages of Dependants Please separate ages with a comma (,)

Physical Address*

Employer*

Phone (Work)

Job Title

Work address

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

Spouse First Name

Spouse Last Name

Spouse ID Number

Spouse Phone (Work)

Spouse Phone (Cell)

Part 3 - Budget Details

Income

Nett Income (Take Home) - Main Applicant*

Nett Income (Take Home) - Spouse

Other Income - Main Applicant

Other Income - Spouse

Living Expenses

Food / Groceries / Clothing - Main Applicant

Food / Groceries / Clothing - Spouse

Property Rental - Main Applicant

Property Rental - Spouse

Water / Electricity / Rates / Levies / Security - Main Applicant

Water / Electricity / Rates / Levies / 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 (Main)

Other - Spouse

Please specify (Spouse)

Part 4 – If Married Out of Community of Property (Antenuptial Contract) and Single Application

Is your spouse employed? YesNo

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 & Account Type

Account Number

Outstanding Balance

Current Instalment

Creditor & Account Type

Account Number

Outstanding Balance

Current Instalment

Creditor & Account Type

Account Number

Outstanding Balance

Current Instalment

Creditor & Account Type

Account Number

Outstanding Balance

Current Instalment

Creditor & Account Type

Account Number

Outstanding Balance

Current Instalment

Part 6 – Previous Debt Review Information

Have you previously been under debt review?* YesNo

Was a court order granted? YesNo

If yes, please give details of the previous debt counsellor

Reason for leaving previous debt counsellor

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 Warriors obtaining my credit report from a registered credit bureau for the purpose of obtaining my credit agreements to assist in the assessment.*

AgreeDisagree

Uploads

Copy of ID - Main Applicant*

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

Copy of latest Payslip*

Copy of latest Payslip - Spouse (If Applicable)

Signatures

Applicant Signature*

Use your mouse or finger to draw your signature above

Spouse Signature

Use your mouse or finger to draw your signature above

Date

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