PERSONAL FINANCIAL SUMMARY
Account Holder 1 Mobile No.
Home Phone No. Home Phone No.
Occupation Work Phone No.
Date of Birth Employer
Employer’s Address No. of Dependants
Home Address
Account Holder 2 Mobile No.
Home Phone No. Home Phone No.
Occupation Work Phone No.
Date of Birth Employer
Employer’s Address No. of Dependants
Home Address
LIABILITIES (OTHER INSTITUTIONS) CREDIT CARDS - LINES OF CREDIT - STORE CARDS - PERSONAL LOANS
Account Number Type of Product Institution Name Balance Owing Monthly Repayment
$ $
$ $
$ $
$ $
$ $
$ $
$ $
$ $
$ $
TOTAL $ $
YOUR ASSETS AND LIABILITIES - HOME LOANS - INVESTMENTS - MOTOR VEHICLES - OTHERS
Assets Institution Name/Lender Total Current Value Balance Owing Monthly Repayments
Residential Property $ $ $
Investment Property $ $ $
Motor Vehicles/Boats $ $ $
Others $ $ $
Others $ $ $
Shares $
Superannuation $
Savings $
Household Items
$
TOTAL $ $
YOUR MONTHLY INCOME AND EXPENSES
Type of Income Net Monthly Income Type of Expense Monthly Payments
Account Holder 1 $ Rent $
Spouse/ Acct. Holder 2 $ Body Corporate/Strata Fee $
Pension/Social Security Benefits $ Land & Water Rates $
Family Assistance/Child Support $ Utilities (Electricity, Gas, Telephone, Mobile, etc.) $
Board/Rent $ Food $
Dividends $ Petrol/Travel $
Interest $ Medical/Health Fund $
Other Income $ Insurance $
$ Other Expenses $
$ $
TOTAL $ TOTAL $
REASONS FOR FINANCIAL DIFFICULTY
DECLARATION
I declare that the particulars in this
statement and accompanying documents are true and correct in every detail disclosing income derived from all sources. I understand that provision of false or misleading
information could result in cancellation of any agreements and the initiation of legal action for debt recovery as can failure to make payments that are owing on any official arrangement.
CUSTOMER’S NAME CUSTOMER’S SIGNATURE DATE
JOINT ACCOUNT HOLDER (If Applicable)
JOINT ACCOUNT HOLDER SIGNATURE
DATE
Please return completed form and supporting documentation to the relevant area
For Mortgages, Please attach confirmation of current building insurance policy or certificate of currency & return with completed form & supporting documentation to the below
Teams
Hardship
Collections
Debt Recoveries
Mortgages
Email Address
DMS.AU@CITI.COM
LM.AU@CITI.COM
DR.AU@CITI.COM
MTGE.COLL@CITI.COM
Mailing Address
PO BOX 3453, Sydney, NSW 2001
PO BOX 3913, Sydney, NSW 2001
GPO BOX 40, Sydney, NSW 2001
GPO BOX 40, Sydney, NSW 2001
Queries Line
1800 722 879
1300
301 531
1300 300 097
1300 300 470
Citigroup Pty Limited ABN 88 004 325 080, AFSL No. 238098, Australian Credit Licence No. 238098
Are you aware of any insurances (such as Consumer Credit Insurance) you hold which may assist with your current situation? Yes No
Thank you for providing your expense information. If your products or services incur standard fees and charges, you may want to consider switching to a basic bank account which can assist you
to manage your finances.
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