Submitting a Financial Statement

In order for us to fully understand your current financial status, we need to know more about your financial situation. As such please complete the following survey, filling in all possible details.

Once you have completed this survey we will send you an automated response to confirm we have received it. Once we have reviewed this survey we will be able to contact you to discuss the matter further.

If you would like to update your details after you have submitted this survey or have a question, feel free to contact us on 1300 799 511 quoting your reference.

Please try to answer all questions. If it does not apply to you, put N/A and the reason it does not apply.

Case Number

Case

Personal Details

Title

First name

Middle Name

Last Name

Other names(Nicknames, Previous Names)

Date of birth

Gender

Street Address/PO Box

Suburb/Town

State

Postcode

Personal Email Address

Mobile Phone Number

Home Phone Number

Marital Status

How many dependents do you have in your care?

What are their ages?

Employment Details

Are you currently employed?

Place of Employment

Position/Title

Street Address

Suburb/Town

State

Postcode

Work Email Address

Contact Number

Email Address

Do you own a company?

Company Name

Is the company registered? If yes, ABN/ACN number?

If unemployed, what is the length of your unemployment?

Will you be starting employment in the near future?

What is the name of your previous employer?

Date of last employment

Contact Number

Income Details

Please attach a copy of your most recent income statement (e.g., tax assessment, payslips, bank statements, etc...)

What income do you receive after tax?

What is the nature of this income (e.g. wages, salary, commission, benefits, etc...)?

If you are not working, what is your primary source of income (e.g. sole parent benefit, disability pension, etc...)? If so, please explain.

Do you have any other sources of income (e.g. part-time work, casual, dividends, rents, etc...)? If so, from what source and how much?

Asset Details

Do you currently own or plan to buy any land or property? If yes, please provide details

Do you currently own or plan to buy a motor vehicle?

Year

Make

Model

Is the motor vehicle registered?

Registration Number

Driver's Licence Number

Is the vehicle subject to finance?

If yes, who is the financier?

How much is owing?

Vehicle value?

Insurance Company

Policy Number

Insurance Broker

Do you have any personal property or assets not previously mentioned? If so, please give details (e.g., include investments, debentures, shares, etc...)

Expenses

Please give details of your expenses calculated on a weekly basis and attach copies of supporting documentation(e.g., bills, bank statements, receipts, etc…)

Rent/Mortgage/Board

Municipal & Water Rates

Food

Telephone

Utilities (Gas/Electricity etc...)

Clothing

Medical/Dental/Pharmaceutical

Entertainment

Insurance (Motor/House/Contents)

Education

Credit Card Repayments (Give details of each loan and balance owing)

Loan Repayments (Give details of each loan and balance owing)

Transportation Expenses (including public transport, vehicle registration, parking, maintenance and fuel)

Other Expenses

Are there any other unpaid debts/fines against you? If so, please provide the following details:

Contact name and nature of money owed

Street Address

Suburb/Town

State

Postcode

Do you have an offer to pay this debt and if so, when and how often can payments be made? Please provide the details below, as well as any other relevant information.

Terms and Conditions

I certify that I have read and accept the Terms and Conditions

Attach Proof of income here