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Name:*

Surname:*

Email:*

Cell Number:*

I.D. Number:*

Are you married?

Yes

If yes, in what capacity?

Married in Community of Property (COP)

Married out of Community of Property (ANC)

Muslim Traditional

African Traditional

Main ID Number:

I/We hereby give consent for my/our credit report(s) to be obtained to determine my level of debt.

Spouse ID Number:

Name:

Surname:

ID Number:

Contact Number:

Employer Name:

Salary Before Deductions:

Salary After Deductions:

Please only complete applicable fields

Food/Groceries:

Rent:

Water/Electricity/Taxes/Levies:

School Fees:

Short-Term Insurance:

Vehicle Insurance:

Life Insurance:

Fuel/Transport:

Medical Aid:

Telephone & Internet:

Other (please specify):

Do you have any bank overdrafts?

Please provide details of any overdrafts, other creditors will be obtained from your credit report

Yes No

If yes, at which bank?

Overdraft Amount:

Have you ever applied for debt review?
Yes No

What was your previous debt counselling agency?

Was a court order granted?
Yes No

I hereby declare that the information supplied by myself in the application form is for myself and is true and correct. I consent to Debt Rescue obtaining my credit report from a registered credit bureau for the purpose of obtaining my credit agreements to assist in the assessment.

Main Applicant's Details

Name:

Date:

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Spouse's Details

Name:

Date:

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Main Applicant

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Upload your latest payslip:

Spouse

Upload spouse's ID:

Upload spouse's latest payslip:

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Main Applicant's Details

Spouse's Details

Main Applicant

Spouse

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Application submitted

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Main Applicant's Details

Spouse's Details

Main Applicant

Spouse

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