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Surname: Office:
NCRDC 1679
APPLICATION FORM FOR DEBT REVIEW FORM 16
MOHAU DEBT COUNSELING SERVICES A division of Mohau Holdings (pty) ltd Reg :2012/058382/07
NCRDDC 1679
HEAD OFFICE
GAUTENG – JOHANNESBURG LENASIA
20 ROSE AVENUE TAHITI CENTRE
OFFICE B5, B6& B7 TEL: 010 590 8067 FAX: 086 659 8947
EMAIL:[email protected] * WEBSITE: WWW.MOHAUHOLDINGS.CO.ZA
NATIONAL TELEPHONE NUMBER :010 590 8067 FAX 086 659 8947
MONTHLY EXPENSES / COMMITMNETS / BUDGET
ITEM RAND VALUE COMMENTS
………………… R……………………. ……………………
……………… R……………………. ……………………
……………… R……………………. ……………………
……………… R……………………. ……………………
……………… R……………………. ……………………
……………… R……………………. ……………………
TOTAL COMMITMENTS: R_________________________
DEPENDANTS
NAME RELATIONSHIP AGE
…………………….. ……………………… ……….
…………………….. ……………………… ……….
…………………….. ……………………… ……….
…………………….. ……………………… ……….
…………………….. ……………………… ……….
Next of kin - 1 Next of kin - 2
Name ……………………. Name:……………………………
Relation ………………….. Relation:………………………..
Address …………………… Address:…………………………..
……………………………. ……………………………………..
Cell number ……………… Cell number ………………………….
Email:…………………………………… Email;………………………………….
Creditors
Institution / Credit provider………………………..Institution / Credit Provider………………………
Balance Owing +- R…………………………………..+-Balance owing R +-…………………………
Installment R+-…………………………………………… Installment R +-…………………………
Institution / Credit provider………………………..Institution / Credit Provider………………………
Balance Owing +- R…………………………………..+-Balance owing R +-…………………………
Installment R+-…………………………………………… Installment R +-…………………………
Institution / Credit provider………………………..Institution / Credit Provider………………………
Balance Owing +- R…………………………………..+-Balance owing R +-…………………………
Installment R+-…………………………………………… Installment R +-…………………………
Institution / Credit provider………………………..Institution / Credit Provider………………………
Balance Owing +- R…………………………………..+-Balance owing R +-…………………………
Installment R+-…………………………………………… Installment R +-…………………………
Institution / Credit provider………………………..Institution / Credit Provider………………………
Balance Owing +- R…………………………………..+-Balance owing R +-…………………………
Installment R+-…………………………………………… Installment R +-…………………………
Signed at ( Place )……………………on the ( day)………………Day of ( Month)……………..201..
Signature Applicant……………………….Print name and Surname………………………………….
Co applicant Signature…………………Print name and surname…………………………………….
MDC Consultant ……………………………..Print name and surname………………………………
ELECTRONIC DEBIT MANDATE
AUTHORITY AND MANDATE IN RESPECT OF ALL ELECTRONIC DEBITS Name of Debt Counsellor / NCRDC no _____________________________________
Name of Account Holder: _________________________________________ Identity Number: _________________________________________ *Compulsory
Applicant Number as per software program: _________________________________________ *Compulsory
Bank: _________________________________________ Account Number: _________________________________________ Branch and Code: _________________________________________ Type of account: _________________________________________
Tracking days: 4 days (if applicable) Tick collection type below: Aedo Naedo MPS
Action Date:
Monthly R
Weekly R
Bi-weekly R
1st Deduction Date
There after
Please note that no other reference than the ID number will be accepted and funds will remain unallocated. DC Partner will take no responsibility should this procedure not be followed.
This signed Authority and Electronic Debit Mandate Mandate refers to our contract dated______________ (" The Agreement ")
1. I/We hereby authorise you to issue and deliver payment instructions to your banker for collection
against my/our abovementioned account at my/our abovementioned bank (or any other bank or branch to which I/we may transfer my/our account) on condition that the sum of such payment instructions will never exceed my/our obligations as agreed to in the Agreement.
2. I/We shall not be entitled to any refund of amounts which was withdrawn while this authority was in force, if such amounts were legally owing to you.
3. I/We acknowledge that all payment instructions issued by you shall be treated by my/our
abovementioned bank as if the instructions had been issued by me/us personally.
4. I/We agree that although this Authority and Electronic Debit Mandate may be cancelled by me/us. Such cancellation will not cancel my Agreement. Notice of cancellation of this mandate must be done in writing 21 days prior to next deduction.
5. I/We acknowledge that this authority may be ceded or assigned to a third party if the Agreement is also ceded or assigned to that third party, but in the absence of such assignment of the Agreement, this Authority and Mandate cannot be assigned to any third party.
Important information 1. A confirmation letter from the bank confirming the account details or bank statement not older than 3 months to be provided 2. The reference which will appear on the client’s statement will be 1st eight characters of DC name 3. All Debit order forms must be provided in 5 working days before first deduction. 4. I agree to pay any bank charges relating to this debit order instruction 5. I understand my monthly payment may increase with ___% annually in _____ as per contract with my debt counsellor
6. Electronic debits will be deducted as per selection above ito date, amount, type of debit and
deduction intervals Signed at __________________________ on this ________ day of ________________________ ________________________________________ Signature of account holder
PERSONAL DETAILS
Full Name: ………………………………………………….Surname: ………...………………………. Maiden Name (If Applicable) : …………………………..Date of Birth : …………………………… Id number : …………………………………………………..Gender:…. Marital Status………… Residential address: ……………………………………………. ……………………………………………. ……………………………………………. ……………………………………………. Tenant / owner ……………………………………Period a t his address ………………… Telephone (Home) ……………………………Fax ( )………………………………… Telephone (work) ……………………………Fax ( ) …………………………………. Mobile / Cell ………………………………….. Email ………………………………….
Main Applicant Employment Details
Employer :…………………………………………………………………Payslip number ………… Address: ………………………………………………………………………………………………….. ……………………………………………………….Postal code………………………………………. Occupation ………………………Employer Tel no. ( )………………… Fax ( )…………………. Employer s address…………………………………………pay office ………………………………… Contact Person……………….........................Telephone / email……………………………………. Pay Office address …………………………………………………..fax ( )…………………………. …………………………………………………..Code ……………………… Period Employed……..
Income
Main applicant Income: R………………………… Deductions R……………….. Incentives R…………………. R………………... R ……………… Other income R……………. Nett Pay: R……………… Spouse / Co applicant Main Income R…………….. Deductions R……………… Incentives R…………………. R ……………… Other income: R……………. R ……………… R ……………… Nett Pay R………………………..
59 Victoria Street, George. PO Box 10311, George
6529
Payment Distribution Agency appointed by the NCR
TEL: 044 – 873 4530 FAX: 0866389079 EMAIL: [email protected]
To whom it may concern
Kindly implement a stop order for the client making use of the following banking details &
references
DC Partner Trust for DC Partner
First National Bank
62265016115
210114
Reference: Consumers 13 digit ID number
I Trust the above is in order.
Should you require assistance or require additional information please don’t hesitate to contact me.
Kind Regards
Elretha Campher
Team Leader: Client Relations
MOHAU DEBT COUNSELLING SERVICES A division of Mohau Holdings (Pty) Ltd Reg 2012/058382/07
Email: [email protected] Web Site:www.mohauholdings.co.za
National Fax to Email Number: 086 659 8947
______________________________________________________________________ DECLARATION BY APPLICANT
I / We declare as follows I /we undertake to comply with all requests from the debt counsellor to assist him/her to evaluate my/our indebtedness and the prospects of or responsible debt in reconstructing. I / We hereby consent to the submission of my / our information to all registered credit bureaus by the debt counsellor. I /We also consent that the debt counsellor may obtain my/our credit records from any / all registered credit bureaus and other registers which may contain any of my / our information. We undertake not to enter into any further credit agreements, other than a consolidated agreement with any credit provider until one of the following events have occurred. The debt counsellor rejects my / our application The court determines that I/ We are not over indebted or: All my /our obligations under credit agreements that are re – arranged are fulfilled. I / We confirm that the information obtained in this document is to the best of my / our knowledge true and correct. I / We undersigned consumers/s hereby agree and undertake to keep the debt counsellor indemnified against any loss or damage from any cause arising which I /we may sustain as a result of this application in terms of Section 86 of the National credit Act 34 of 2005. I/We were properly informed of the consequences of debt review that whilst I / we are under debt review we will not access credit and that should I/We decide to withdraw pre maturely that is before all of my / our creditors are settled and paid up in full we will seek assistance of an attorney to remove me/us from debt review. Tick to accept the terms of this declaration. Main Applicant Signed at (Place)………………………………………………..on this ……………..day of ………………………………..201. Signature ......................................................Print Name ………………………………………………………………… Witness Signature ……………………………………….Print Name ……………………………………………………………… Spouse / Co applicant Signed at (Place)………………………………………………..on this ……………..day of ………………………………..201. Signature ......................................................Print Name ………………………………………………………………..
Witness Signature……………………………………….Print Name ……………………………………………………………….
