Free
Debt
Assessment
Please complete the form and email it back to us
1. Personal Information
1.1 Title
1.2 Full Names
1.3 Surname
1.4 Maiden Name (if applicable)
1.5 ID Number
Passport Number (nonRSA)
1.6 Date of Birth (yyyymmdd)
1.7 Gender
1.8 Residential Address
Post Code
1.9 Postal Address (if not the same)
Post Code
1.10 Email Address
1.11 Home Telephone
1.12 Work Telephone
1.13 Cell Number
1.14 Where did you hear about us?
2. Marital Status
2.1 Marital Status
2.2 Marriage Type
2.3 Number of Dependants
3. Employment Details
3.1 Occupation
3.2 Name of Employer
3.3 Start Date of Employment
3.4 Duration of Employment
4. Additional Information
Include any additional information which may be relevant to your debt assessment:
1st Applicant
2nd Applicant
1st Applicant
2nd Applicant
1st Applicant 2nd Applicant
Page
1 of 3
NCR Reg No: NCRDC1142
Tel: 087 701 9665
Fax: 086 649 6252
www.zerodebt.co.za
Mr
Mrs
Male
Female
Google
Single
Single
Not Applicable
Not Applicable
0
0
(Form 16)
5. Monthly Net Income Calculation (all amounts to be entered as positive values)
Income
Gross Monthly Salary
Total Allowances
Total Subsidies
Commission (Monthly Equivalent)*
Other Income (Specify Below):
Total Income
* Income that is received on an annual basis should be converted to a monthly equivalent (divided by 12)
Deductions
Income Tax PAYE
UIF
Medical Aid
Pension Fund Contributions
Garnishees
Other Deductions (Specify Below):
Total Deductions
Expenses
Property Rent *
Water, Electricity & Services
Rates and Taxes
Telephone / Cell / Internet
Insurance Short Term
Insurance Life
Medical Expenses
School & Other Education Fees
Transport / Vehicle Costs
Domestic & Gardening Services
Bank Charges
Clothing
Groceries
Security Costs
Maintenance Payments
Other Expenses (Specify Below):
Total Expenses
Available for Distribution **
* Note: Home loan payments and any other payments like vehicle financing should be included in the list of credit providers below
and not duplicated in the Expenses section.
** Note: The available for distribution amount above reflects the funds which are available for a consolidated debt repayment.
1st Applicant
2nd Applicant
1st Applicant 2nd Applicant
2nd Applicant
Page 2 of 3
NCR Reg No: NCRDC1142
Note: Amounts that are included as deductions should not be included in the Expenses section.
1st Applicant
Net Pay
R 0.00
R 0.00
R 0.00
R 0.00
R 0.00
R 0.00
R 0.00
R 0.00
R 0.00
6. List of Credit Providers (Home Loans, Unsecured Loans, Credit Cards, etc.)
Name of Credit Provider Outstanding Debt Monthly Payment
Total
Page 3 of 3
NCR Reg No: NCRDC1142
Description
R 0.00
R 0.00
By completing this form I give consent to draw a credit report
Signature
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