APPLICATION TO PAY BY INSTALMENTS
We will consider freezing the interest and legal costs on your debt if you carefully complete this document and make an offer to pay by monthly instalments.
(All requests treated in the strictest confidence)
First Name:______Our Ref No.
Surname: ______
Maiden Name/Surname (prior to being married): ______
Address:______
Telephone:______Mobile:______
Date of Birth: ______E-mail: ______
Home Details:OwnerTenant With Parents With Partner
Spouses Name: ______
If you answer Owner, please complete the following:
(a)Residential Property:
______
Value of Mortgage: ______
Folio Number(s): ______
Name of Lending Institution: ______
(b)Investment Property:
______
Value of Mortgage: ______
Folio Number(s): ______
Name of Lending Institution: ______
(c)Commercial Property:
______
Value of Mortgage: ______
Folio Number(s): ______
Name of Lending Institution: ______
(d)Pension-Related Investments:
______
Value of Fund: ______
Annual Contribution: ______
Pension Fund Name: ______
OTHER ASSETS/LIABILITIES
(NB – give details: Description of Asset, Asset Value, Debt, other relevant information)
______
______
______
______
Status:Single MarriedDivorced/Separated
No. of dependant children under 18: ____ Do they live with you? _____
Other dependants if any:______
Employment details:* Employed full time
* Employed part time
* Self employed
* Unemployed
PPS Number: ______
Occupation: ______
Gross income from Employment: ______
Gross income from Other Sources: ______
Other Household Income (e.g Spouses income): ______
Employer’s name & address: ______
If you answer Self Employed, please confirm the following:
Do you hold any shares in the Company: ______
Number/Value of Shares: ______
Do you hold Share in any other Company (e.g. PLC): ______
Name of Company: ______
Number/Value of Shares: ______
Reason for financial difficulties: ______
______
Details of Income
Wages/Salary:€______weekly/monthly (delete as appropriate)
Wages/Salary – Partner€______weekly/monthly
Unemployment Benefit€______
Child Benefit€______
Pension€______
Maintenance€______
Other income(give details)€______
Details of Expenditure each Month:
Mortgage/Rent€______
Life Insurance€______
Fuel (Gas, ESB, Oil etc.)€______
Housekeeping€______
Telephone€______
Car Loan€______
Motor Expenses€______
Medical Bills€______
Other Expenditure€______(give details)
Creditor Payments :Per MonthBalance Due (Approx.)
Credit/Charge Cards€______€______
Bank Overdraft€______€______
Bank Loans€______€______
Credit Union€______€______
Court Orders€______€______
Other (give details)€______€______
I declare that this document is an accurate record of my financial position and on this basis I offer to pay the sum of :
€______each month (subject to review in 6 months) until the agreed debt is paid.
Signed: ______Dated: ______