Application Information

Fax back to 0866186003 or email to maritha@insolvensies.co.zaHusband:

NOTE: (If married out of community of property and only wife applies, we also need the

following information of husband **)

Full Names:**

Surname:**

Referred to as:

ID Number:**

Place of Birth (Town)?

Residential Address:

Period at above address:

Postal Address:

Home Telephone number:

Cellular Number

Work Telephone Number:

E-mail Address:

(To keep you also updated)

Occupation:

Employer:

Period employed at current employer?Marital Status (in community / with

anc / divorce / single)

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If married: Date

If Divorced: Date

Wife:

NOTE: (If married out of community of property and only husband applies, we

also need the following information of wife **)

Full Names:**

Surname:**

Referred to as:

ID Number:**

Place of Birth (Town)?

Residential Address:

Period at above address:

Postal Address:

Home Telephone number:

Cellular Number

Work Telephone Number:

E-mail Address:

(To keep you also updated)

Occupation:

Employer:

Period employed at current employer?Marital Status (in

community / with anc /

divorce / single)

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If married: Date

If Divorced: Date

Contact details of next of kin in

the event of an emergency

Where did you hear about us:

Beeld Burger Junk Mail Sherrif: Website

Google NCR: Referred by? Friends: Referred by?

Personal Information:

Income

Nett salary (after deduction) Husband:

Is the salary fixed or commission based?

In event of commission state the average for the past 3 months?

Nett salary (after deduction) Wife:

Is the salary fixed or commission based:

In event of commission state the average for the past 3 months?

Dependants/Children

If divorced – Do you receive maintenance and how much?

Do you pay maintenance – if yes how much?

Number of underage children:

Age of children:

Monthly School fees:

Day Care/Additional education/Other activities:

Transport cost for children (e.g. bus / Lift Club)

Study costs (e.g. University) and book fees:

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Boarding Costs:

HOUSING COSTS

Rent / bond costs per month:

Municipal Accounts per month:

Do you receive rent, how much?

MEDICAL EXPENSIS

Do you have a medical aid fund? What is the monthly instalment:

(this is not part of the application: you are entitled to a medical aid)

Additional medical expenses?

If you do not have a medical aid fund, how much do you spend monthly:

Is one of your dependants suffering due to a medical condition (diabetic / cardio

vascular / blindness / deaf / etc)

MONTHLY EXPENSES

Monthly groceries costs (Milk; bread; meat etc): (estimated costs)

Do you borrow a vehicle - if yes where?

How much do you pay monthly for the vehicle?

Average petrol costs/month?

Funeral policy monthly instalment?

Cellular phone expenses?

FINANCIAL HISTORY

Have you already applied for debt counselling?

Was a court order issued for you debt counselling? YES/NO Date:

What is/was the instalment?

Have you ever been under administration?

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Have you ever been sequestrated?

If yes state date?

Who was the curator appointed by the Master of the High Court?

Date of rehabilitation?

PROPERTY INFORMATION:

Do you have a

property

registered in your

name or a bond?

Have property with bond No Property - Renting

Have property without a

bond

Have more than one property,

(Provide information on all properties)

Property 1

Plot Number (if available)

Street address

Amount purchased for:

Amount outstanding on bond:

Bondholder (state bank):

Bond Account Number:

Are you selling the property? If

yes since when in market?:

For what price are you

marketing:

Are you renting the property

out, or are you the occupant?

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Did someone sign surety for

the bond?

Did the bondholder schedule

an auction? If yes, please list

date?

Property 2

Plot Number (if available)

Street address

Amount purchased for:

Amount outstanding on bond:

Bondholder (state bank):

Bond Account Number:

Are you selling the property? If

yes since when in market?

For what price are you

marketing?

Are you renting the property

out, or are you the occupant?

Did someone sign surety for

the bond?

Did the bondholder schedule

an auction? If yes, please list

date?

VEHICLE INFORMATION

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Vehicle 1: Fabricate

Model (year)

Registration number

Hire Purchase or Lease

Monthly instalment

Financed By (which

bank)

Is the payment up to

date?

Estimated value of

vehicle

Vehicle 2: Fabricate

Model (year)

Registration number

Hire Purchase or Lease

Monthly instalment

Financed By (which

bank)

Is the payment up to date

?

Estimated value of

vehicle

Reasons For Sequestration

(Provide all details that caused your situation – it is of utmost importance to be specific

regarding the information that caused your financial problems - you have to include all

aspects such as - maintenance paid, caring and financial support given to relatives,

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unforeseen expenses, retrenchment, medical expenses not covered by medical aid, etc etc

etc. PLEASE NOTE that a proper list of reasons must be submitted to the High Court. Stating

that your Expenses is more than your Income is not sufficient. PLEASE PROVIDE US WITH

THE REASONS THAT CAUSED THE FINANCIAL PROBLEMS YOU ARE FACING AT PRESENT.

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Creditors

List ALL creditors (Everybody that you owe money, including family). We have all the addresses of the known creditors such as banks, clothing stores and cellular

companies. What WE NEED are the addresses of Doctors, Cash loans and unknown institutions and family addresses. It is important to supply the addresses as

they are to be notified by means of Registered post. ALL account numbers are vital to be included. Also provide proof in the form of the last statement

received from the financial institution.

Institution Instalment Outstanding Amount

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Institution Instalment Outstanding Amount

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Any additional information that you want me to know or may be used in the application.(It is important to provide and disclose all information in order to provide an effective service- do NOT keep vital information out of your application!)

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SUMMARY

We need the following documents (proof of payment) to prepare the

Application for Insolvency:

1. Copy of ID document or Passport

2. Receipt for Rent paid or Rental Agreement

3. Salary slip

4. Maintenance payments (if applicable)

5. School / University / College Fees

6, Payment of after care or extra mural activities

7. Water & Electricity / Municipal accounts

8. Proof of Medical Aid payments

9. Medical expenses not paid by Medical Aid

10. Proof of monthly car rental

11. Payments for funeral cover or other life policies

12. Cellphone accounts / pre-paid slips

13. Proof of Debt Counselling (if applicable)

14. Proof of monthly payments for Debt Counselling

15. We do need the latest statements of all creditors. If you

do not receive any statements, please request the

redemption amount from you creditors. If any of your

accounts were handed over please furnish us with a

statement from the atornies.

16. Any other monthly payments

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