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Hi, please fill in your details below:
ABOUT YOU:
Name:*
E-mail:*
Cell Number:*
ID Number:*
Address:
Referred by?:
Referred by cell number:
Business Name:
Expertise:
Marital Status:*
Number of dependents:
Age of dependents:
Family description:
Have you ever been under debt review?*
Do you have any garnishee order/s on your salary?*
Do you have any court action/s against you at this time?*
Brief outline of your problem:
Short Income and Expense
Income
Nett income:*
Expenses
Bond repayment / rent:
Water & Electricity / Rates & Taxes
Vehicle Lease:
Petrol / Transport:
Telephone – Cel / Landline:
Medical Aid:
School Fees:
Total Expenses:*
Expenses General Comments:
Creditors
Total bond outstanding:*
Total vehicle outstanding:*
Total of all other debt outstanding:*
Creditor General Comments:
Debt Management Instructions
Banking Details -
I, the abovenamed am duly authorised hereto do hereby instruct Debt Management to act as my Debt Manager / Adviser / Legal Representative / Assistant in the matter to manage my debts (outside of the provisions of Section 74 of the Magistrate's Act and Section 87 of the National Credit Act.)1.1. I acknowledge that I am aware that:1.2. you are not taking instructions in terms hereof as an attorney; and1.3. you are not a debt counselor; and1.4. contact made with my creditors by you may / will make specific mention of my inability to make payments to them in accordance with my agreements constitutes an act of insolvency entitling such creditor/s to bring an application to sequestrate my estate; and1.5. the consequences/costs of closing / changing my current bank a/c have been fully explained to me; and1.6. I will refer creditors to you to deal with any queries received from them; and.1.7. I instruct you not to provide any creditor with any of my personal details other than necessary to fulfill your instructions hereunder; and1.8. in my name, place and stead, to defend any Formal B-Creditor Collection Proceedings, to sign any court documents on my behalf in relation thereto and generally for effecting the purpose aforesaid to do whatsoever shall be necessary as fully and effectually as I might or could do if personally present, hereby ratifying whatsoever you shall do by virtue of this authority including the settlement or withdrawal thereof on terms in your sole discretion including the tender of costs.1.9. No sums paid to you are for payment over to my various creditors.2. I hereby authorise and instruct you to deduct from the undermentioned account the sum of R150-00 gross per month, starting the month following completion hereof, excluding disbursements to be incurred by prior agreement thereafter until canceled/terminated by sms / email / fax;2.1. I further understand and acknowledge that there is no notice period for the cancellation/termination of this Mandated Authority to debit the undermentioned account;2.2. I still further understand and acknowledge that if the payment instruction falls over a weekend or a RSA public holiday, payment will be made on the next ordinary business day;2.3. I still further understand and acknowledge that the payment instruction issued from this Mandate will be treated as a payment instruction issued personally by the account holder;2.4. I still further understand and acknowledge that canceling/terminating this mandate does not cancel the Agreement. I hereby specifically and unequivocally agree that the account holder is not entitled to a refund of any monies deducted for when the Mandate was still active if such amounts were owed to them;2.5. I still further understand and acknowledge that this Authority may be assigned to a third party if this agreement is also assigned to a third party:
Bank name:*
Account holder:*
Account type:*
Account number:*
Branch code:*
Preferred Day of Debit Order is the 1st working day of the month.
Debit order date:*
Debt Management (both for itself and on behalf of its servants and agents) is instructed on the basis that it or its servants and agents does not accept any liability for any act, omission, default or neglect (including gross negligence) by it or its servants and agents for any injury, damage or loss to myself or any other person/s whatsoever and howsoever the same may be caused and Debt Manager and my agent does not warrant, and is in no way responsible for the accuracy of any information given or statement made by itself or its servants and agents or given or made by itself or its servants and agents in connection with the authority hereby granted.
Acceptance:*
By checking the above box you agree and hereby authorise and instruct Debt Management to deduct from the abovementioned account the sum of R150-00 gross per month plus vat (when / if chargeable) and / or disbursements (to be incurred only by prior agreement thereafter until cancelled by sms / email / fax).Debt Management reserves its right to renegotiate the above sum of R150-00 in the event that your use of Debt Management's services is / are disproportionate to the above monthly fee.
When the Debit Order goes off the following agreement reference number will appear on your statement for example:

A J WEBBST ao1014 (the current month and year) tw111 (your unique code - this code is only an example)
When the Debit Order goes off the following agreement reference number will appear on your statement for example:

A J WEBBST ao1014 (the current month and year) tw111 (your unique code - this code is only an example)
Word Verification: