Total Monthly Household Income
(Net Salary & Other
Household Expenses per Month
Bond Repayment / Rent
Rates, Water & Electricity
(Excluding those to be settled)
Personal Loan Repayments
Credit Card Repayments
Policy / Insurance repayments
Food & Entertainment
Total Monthly Household Expenses
Household Surplus / Disposable Income
Are you Currently Liable as:
If you have signed Surity or Co-Debtor, Please indicate the full amount Outstanding
I Confirm that:
A. I am not a minor.
B. I have never been declared mentally unfit by a court.
C. I am not subject to an administration order.
D. I do not have any current application pending for debt restructuring or alleviation.
E. I do not have any current debt re-arrangement in existence.
F. I have not previously applied for a debt re-arrangement.
G. I am not unde sequestration.
H. I do not have applications pending for credit,
nor open quotations as envisaged in section 92 of the National Credit Act.
I. If any of the above is incorrect, give details:
Decleration by Client:
I hereby grant the Credit Provider the right to communicate with me throught any electronic/written media or verbally in order to make available to me, teir product offering
I hereby grant the Credit Provider the right to increase my Credit Limit once every year to accommodate ant Value Added Products needed and requested by me.
I hereby give consent to the Credit Provider to make enquiries about my credit record with anty credit agency and to obtain whatever information on me they might require to process the application. I also give consent to the Credit Provider to share my payment behaviour with any credit agency.