MAGISTRATES COURT OF QUEENSLAND
REGISTRY:
NUMBER:
Plaintiff:
AND
Defendant:
STATEMENT SUPPORTING APPLICATION BY ENFORCEMENT DEBTOR FOR ENFORCEMENT WARRANT – INSTALMENTS
Enforcement Creditor: (name)
Enforcement Debtor: (name)
(Full name of deponent) of
(Residential or business address, or place of employment),
(Occupation or other description)
States on oath [or solemnly and sincerely affirms and declares]:
1. I am the enforcement debtor.
2. The enforcement creditor obtained a money order against the enforcement debtor in the Court on (date) for an amount of $ .
3. The date and amount of each payment made under the order are (detail of payments, if any)
- I am married/single/divorced with _____ dependants
5. The name of my employer is:
- My nett income (Gross less tax) per week/fortnight/month is $______
7. Additional income received from other sources (i.e., commission, etc) per week/fortnight/month is $______
Total Income per week/fortnight/month$______
8.Assets (You must list all property owned by the enforcement debtor or in which that person has any interest)
Real Estate – state address of any properties and market value
……………………………………………………………….$......
……………………………………………………………….$......
Money in banks, building societies, credit unions and similar
Financial institutions – state name of institution, account
number and amount………………………………………….$......
……………………………………………………………….$......
……………………………………………………………….$......
Money on hand$......
Life Insurance Policies – state name of insurer, policy number
And surrender value………………………………………….$......
Shares and debentures – state name of corporation, number of
Shares held and market value…………………………………$......
Interest in business, partnership etc – state name of business,
Partnership and market value
………………………………………………………………..$......
Motor vehicles and vessels – state Make, Model, year and
Registration number and current market value
………………………………………………………………..$......
………………………………………………………………..$......
………………………………………………………………..$......
Furniture and other household goods – market value$......
Personal Property – state details and market value
………………………………………………………………..
………………………………………………………………..$......
Money owing to the enforcement debtor from other sources –
State who owes money………………………………………..$......
………………………………………………………………...$......
9. Expenses per week/fortnight/month:
Rent/Mortgage:$______
Food and general household supplies:$______
Electricity/Gas:$______
Telephone:$______
Medical, dental, optical, ambulance, & pharmacy:$______
Motor Vehicle (inlcuding registration, insurance, maintenance):$______
Entertainment & other recreational expenses:$______
Credit Cards, store cards, etc$______
Personal Loans:$______
Any other expenses:$______
$______
Total Expenses per week/fortnight/month$______
10.In addition to the aforementioned judgment, I have the following liabilities (i.e. details of loans, credit cards, etc):
11. (Insert any other information in respect of the orders being sought)
12. The amount I propose to pay toward the judgment per week/fortnight/month, should my application, be accepted is $ .
Sworn [or: Affirmed] by (full name of deponent) at on (date)in the presence of:
______
Deponent – Enforcement DebtorJustice of the Peace/Solicitor
NOTE
This statement must be sworn not earlier than 2 business days before the date of the application for the enforcement warrant (R.817)