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ABOUT YOU

Title (required):

First Name (required):

Surname (required):

ID Number (required):

Passport Number:

Marital Status(required):

Work Phone:

Home Phone(required):

Cell (required):

Fax Number:
E-mail Address:

Home Address (required):

Postal Code (required):

Postal Address (required):

Postal Code (required):

Number of Children / Dependants (required):

Age:

Gender:

Race:

Debt counselling is ideally done with an individual and their partner. If you are together with somebody, but keep your finances completely separate then it is not necessary to complete the next section. However, if you are married in Community of Property then you must complete your spouse's details here as the application must be made in both your names.

About your Spouse or Partner who lives with you (Where applicable).

Title:

First Names:

Surname:

ID Number:

Passport Number:

Age:

Gender:
Race:

Work Phone:

Home Phone:

Cell:

Fax Number:

E-mail Address:

About your employment

Company Name (required):

Employee Number (required):

Employer's Telephone Number (required):

Employer's Address (required):
Increase Month:

Do you receive an annual bonus:

Employment Sector (required):

Pay Day (required):

INCOME

Net (Take Home) Pay (required):

Other Income:

Description of Other Income:

PAY SLIP DEDUCTIONS
Pension Fund:

Medical Aid:

Loans:

Union subscription:

Insurance:

UIF:

Group Life:

RA’S / Endowment:

Garnishees / Admin Order:

Funeral Policy:

Other:

Tax (SITE and PAYE) (required):

Bank Name:

Branch:
Account Number:

Account Type:

How do you spend your money?

Domestic Worker:

Gardener/Service:

Meat:

Bread & Milk:

Vegetables & Fruit:

Other Groceries:

Water & Electricity:

Land Line Phone:

Cell Phone:

Internet:
Security:

Cigarettes & Liquor:

Bus/Taxi/Train:

Petrol:

Parking:

Car Maintenance:

Rates & Taxes:

Home Maintenance:

Body Corporate Levies:

School Fees:
University/Tech Fees:

Crèche:

Clothing:

Rent/Board:

Assurance:

Insurance:

Medical Aid:

Pension:

Other Financial Services:

Other:

TOTAL MONTHLY LIVING EXPENSES (required):

Affordability to Repay Debt:

Are You Human:

I have read the declaration

NCR-Logo

Dee Raghubir – Debt Counsellor(NCRDC420)

Registered with the National Credit Regulator
Certified Associate of the Institute of Bankers in S.A.
Management Development Programme – UNISA
Debt Counselling Assoc of SA
National Debt Mediation Assoc

DOCUMENTS REQUIRED

  • Copy of your bar coded identity document
    (and spouse if married in community of property)
  • 3 month salary advice
  • 3 month bank statement
  • Statements on all accounts
  • Statement of income and expenses
    (joint if married in community of property)
  • Letters, if any, from credit providers, attorneys or debt collectors

ADDRESS


Suite 101, Wakefield House, 79 Crompton Street, Pinetown, 3610

TELEPHONE


031 701 7689
083 284 9338
078 244 9959

FAX & EMAIL


Fax:
086 542 4775

Email:
info@moneymsolutions.co.za