Submit Details

First Names *

Surname *

ID Number *

Nick Name

Birth Date (DDMMYYYY)

Gender *

Preferred Language *

Dependants - relationship, name and age

Marital Status

E-Mail Address

Telephone Home

Cellular Phone Number

Work Number

Fax Number

Street Address

Town

Postal Code

Postal Address

Town

Postal Code

Employer

Employer Number

Employment Date

Occupation

Salary Date

Reason/s for financial difficulty

Income: Own Salary Gross Income

Total deductions own salary

Income: Spouse Salary Total Income

Total deductions spouse salary

Other Income (mention source)

Expenses: Life Insurance

Expense: Insurance - Car/House

Expense: Household/Domestic

Expense: Education

Expense: Entertainment

Expense: Family

Expense: Groceries

Expense: Home Ownership Cost /Rent

Expense: Medical

Expense: Pension

Expense: Petrol /Travel

Expense: Security

Expense: Telephone

Expense: Water and Electricity

Expense: Other (please provide detail)

Fields marked with * are required.

Kindly provide copies the following documents if available (if some of these documents are not available at present you may submit it later after discussions with the Debt Counsellor) -

- Most current salary slip

- Identity Document/s

- Proof of Residence

- Bank statements of three most recent months

- Most recent statements of accounts received

E-Mail: dc@debtc.co.za or

Fax: 011 366 1521 or

Whatsapp: 082 448 7204

General Information:

An applicant married in community of property: please provide the information of your spouse and submit as a separate form.

Applicants married with Antenuptial Contract: please provide a copy of the Antenuptial contract if only one of the spouses apply.

Kindly remember to inform us of any changes in your address, contact numbers or other particulars. Hint: it is easy to use the message box here on the right hand side for this purpose.