GUY JAMES & ASSOCIATES CC

CERTIFIED DEBT COUNSELLORS

Guy F. James, NCRDC280

108 HENDERSON STREET, ROSEACRE, JHB, 2197

TEL: 011-869-5207/7428 & 011-024-5762 FAX: 086-647-7343

Email: Website:

FORM 16

APPLICATION BY CONSUMER FOR DEBT REVIEW IN TERMS OF SECTION 86 OF THE NATIONAL CREDIT ACT, 34 OF 2005

Please note that:

  1. On receipt of this application the Debt Counsellor will advise all credit providers and all registered credit bureaus that you have applied for review;
  1. You will be listed with all registered credit bureaus that you have applied for debt review;
  1. This form must be accompanied by a list of all credit providers as well as copies of all documents requested;
  1. Should documents not be submitted within 10 days of Application being received by the Debt Counsellor, your application will be terminated and not accepted.

PART 1 – PERSONAL INFORMATION OF 1ST APPLICANT

FULL NAME & SURNAME______

IDENTITY NUMBER:______

PHYSICAL ADDRESS:______

______

______

TELEPHONE NUMBER (WORK)______

TELEPHONE NUMBER (HOME)______

CELLPHONE NUMBER______

NAME OF EMPLOYER:______

ADDRESS OF EMPLOYER:______

______

OCCUPATION:______

MARITIAL STATUS: ______

NUMBER OF DEPENDANTS:______

PERSONAL INFORMATION OF 2nd APPLICANT

FULL NAME & SURNAME______

IDENTITY NUMBER:______

PHYSICAL ADDRESS:______

______

______

TELEPHONE NUMBER (WORK)______

TELEPHONE NUMBER (HOME)______

CELLPHONE NUMBER______

NAME OF EMPLOYER:______

ADDRESS OF EMPLOYER:______

______

OCCUPATION:______

MARITIAL STATUS: ______

NUMBER OF DEPENDANTS:______

PART 2 – INCOME & DEDUCTIONS

INCOME1ST APPLICANT2ND APPLICANT

Basic Salary______

Overtime______

Car Allowance______

Petrol Allowance______

Housing Allowance______

Travel Allowance______

Shift Allowance______

Commissions (Bonuses)______

Rental income______

Other Income______

Gross Income______

DEDUCTIONS

Tax______

Pension______

Medical Aid______

UIF______

Union Dues______

Other______

Total Deductions______

NET INCOME______

PART 3 – MONTHLY COMMITMENTS

DETAILS1ST APPLICANT2ND APPLICANT

Rent______

Electricity & Water______

Rates & Levies______

Groceries & Living Expenses______

Phone / Cell Expenses______

Insurance - Car______

Insurance - Home______

Insurance – Life______

Insurance - Other______

Petrol / Transport Costs______

Medical / Prescriptions______

School / Daycare Fees______

Clothing (Children) ______

Security______

Aftercare / Maid______

Garden Services______

DSTV / TV Licenses______

Family Maintenance / Court order)______

Other______

Other ______

Total Monthly Commitments______

FUNDS AVAILABLE______

COMMENTS:

PART 4 – DEBT OBLIGATIONS / CREDIT PROVIDERS

CREDIT TYPE / CREDIT PROVIDERS / O/S BALANCES / MONTHL PAYMENT / INTEREST % / ACCOUNT NUMBER / ARREARS

PART 4 – SCHEDULE OF ASSETS

DETAILS1ST APPLICANT2ND APPLICANT

Houses______

Cars______

Household Items______

Other______

Other______

TOTAL ASSETS______

PART 5 – DECLARATION BY THE CONSUMER(S)

I DECLARE AS FOLLOWS:

  1. I undertake to comply with all requests from the Debt Counsellor to assist him/her to evaluate my state of indebtedness and the prospects for responsible debt restructuring;
  1. I hereby consent to the submission of my information to all registered credit bureaus by the debt Counsellor;
  1. I also consent that the Debt Counsellor may obtain my credit record for any/all registered credit bureaus and any other registers which may contain any of my credit information;
  1. I undertake not to enter into any further credit agreements, other than a consolidated agreement, with any Credit Provider until one of the following events have occurred:

a) The Debt Counsellor rejects my application;

b) The court determines that I am not over-indebted; or

c) All my obligations under credit agreement as re-arranged are fulfilled;

  1. I confirm that the information contained in this document is, to the best of my knowledge, true and correct.

______Signature of Consumer – 1 Signature of Consumer - 2