Contact DetailsFull Name* First Last Have you previously gone by any other name? First Last Email* Phone*Date of Birth Living ArrangementsMarital Status*Please Select...SingleMarriedDefactoSeparatedSpouse/Partners Name First Last DependantsDependant First NameDependant Last NameDependant Age Current ResidenceCurrent Residency*Please Select...OwnMortgageRentingBoardingFree AccomodationHow long at current Address?*Current Residential Address* Street Address Suburb State Post Code Previous ResidencePrevious Residential Address Street Address Suburb State Post Code How long at previous address?Did you own this property?Please Select...YesNoIf sold, what year was it sold?Personal ReferencePlease provide the contact details of a personal reference who does not live with you. We will only attempt to contact this person if we fail to make urgent contact with you.Name* First Last Relationship to you*Phone*Personal Reference Address* Street Address Suburb State Post Code Employment DetailsEmployment Status*Please Select...Full TimePart TimeCasualUnemployedName of Employer (Company Name)*Job Title*Hours of work completed per week*Industry*Income for the last 12 months*Expected income for the next 12 months*Income Frequency*Please Select...WeeklyFortnightlyMonthlyAddress of Employment Street Address Suburb State Post Code Time Unemployed*Name of previous employer (company name)Debt OverviewI have Secured Debt.*Secured Debt includes any finance secured over an asset (e.g. Home Loans, Car Loans, Leased Equipment or Rental Goods).Please Select...YesNoI have Unsecured Debt.*Please include all Unsecured Debt (Credit Cards, Store Cards, Personal Loans, Overdraft Facilities, ATO Debt & Overdue or Disconnected Bills).Please Select...YesNoSecured Debt*Type of Debt...Creditor NameCard/Account/Reference NumberRepayment AmountRepayment FrequencyAsset ValueJoint?Hardship?Amount Owing Please Select...House MortgageVehicle LoanLeaseEquipment HireBusiness SecurityOtherPlease Select...WeeklyFortnightlyMonthlyPlease Select...YesNoPlease Select...YesNo Unsecured Debt*Type of Debt...Creditor NameCard/Account/Reference NumberRepayment AmountRepayment FrequencyAge of DebtJoint?Hardship?Amount Owing Please Select...Credit CardStore CardPersonal LoanOverdrawn AccountBill of SaleOtherPlease Select...WeeklyFortnightlyMonthlyPlease Select...YesNoPlease Select...YesNo Value in Assets Owned OutrightThese are assets you own outright. In other words, you don't owe any money for the following items.Cash SavingsJoint Owned?Please Select...YesNoProperty (Please advise below)Joint Owned?Please Select...YesNoVehicles (Please advise below)Joint Owned?Please Select...YesNoBusiness Tools and AssetsJoint Owned?Please Select...YesNoInvestments/Shares/Managed FundsJoint Owned?Please Select...YesNoFurniture and Household ItemsJoint Owned?Please Select...YesNoVehicles OwnedVehicles OwnedMake/Model/YearTransmissionIs this vehicle for sale? Please Select...AutomaticManualPlease Select...YesNo Properties OwnedIf you indicated you owned property in the table above, please provide details here.Properties OwnedProperty AddressProperty ValueIs the Property for Sale? Please Select...YesNo Your Weekly IncomePlease enter Net amount after tax.Wages/Salary (after tax) Job 1Wages/Salary (after tax) Job 1 - youWages/Salary (after tax) Job 1 - spouseWages/Salary (after tax) Job 2Wages/Salary (after tax) Job 2 - youWages/Salary (after tax) Job 2 - spouseCentrelink BenefitsCentrelink Benefits - youCentrelink Benefits - spouseChild Support/Maintenance ReceivedChild Support/Maintenance Received - youChild Support/Maintenance Received - spouseRental Income (incl board, contributions from children)Rental Income - youRental Income - spouseBusiness IncomeBusiness Income - youBusiness Income - spouseOther IncomeOther Income - youOther Income - spouseTotal Weekly IncomeTotal Weekly Income - youTotal Weekly Income - spouseWeekly ExpensesRent/board/mortgage repaymentsRent/board/mortgage repayments - youRent/board/mortgage repayments - spouseRates/Household ExpensesRates/Household Expenses - youRates/Household Expenses - spouseFood (incl groceries and take away)Food - youFood - spousePhone, mobile, internetPhone, mobile, internet - youPhone, mobile, internet - spouseEntertainment (alcohol, books, cinemas)Entertainment - youEntertainment - spouseElectricity, gas, waterElectricity, gas, water - youElectricity, gas, water - spouseHealth Insurance, medical, chemistHealth Insurance, medical, chemist - youHealth Insurance, medical, chemist - spouseCar payments to a secured creditorCar payments to a secured creditor - youCar payments to a secured creditor - spouseOther transport (incl fuel, rego, servicing)Other transport - youOther transport - spouseOther Insurance (home, content, income protection)Other Insurance - youOther Insurance - spouseChild Care/School fees and expensesChild Care/School fees and expenses - youChild Care/School fees and expenses - spouseChild Support/Maintenance paymentsChild Support/Maintenance payments - youChild Support/Maintenance payments - spouseOther expenses for children (lessons, uniforms, sport)Other expenses for children - youOther expenses for children - spouseClothes, shoes, hairdressers, etcClothes, shoes, hairdressers, etc - youClothes, shoes, hairdressers, etc - spouseIncidentals (cigarettes, magazines)Incidentals - youIncidentals - spousePayments to secured creditorsPayments to secured creditors - youPayments to secured creditors - spouseOther ExpensesOther Expenses - youOther Expenses - spouseTotal Weekly Expenses Total Weekly Expenses - youTotal Weekly Expenses - spouseBusiness DealingsIf you currently operate a business or own a company or trust, we may require you to complete a short Business Dealings Form. Otherwise, you may proceed to the next section.Do you currently own/operate a business?*Please Select...CompanyTrustPartnershipSole TraderI don't own/operate a businessFinancial DetailsPlease detail in your own words how this situation has come about.*This information will be relayed to your creditors and used by them in their consideration of your proposal.Insolvency HistoryHave you declared Bankruptcy or entered into any other kind of Insolvency Agreement?*Please Select...I have declared BankruptcyI have entered Part 9 Debt AgreementI have entered a Part 10 Debt AgreementI have entered a Personal Insolvency AgreementI have entered a Debtstroyer AgreementI have entered an informal debt agreementNoWhat year was it finalised/terminated?*Are you currently up-to-date with payments to your creditors?Please Select...YesNoLast able to pay your debts as they fell due?* Your InsolvencyWhat steps have you taken to manage your debts? Spoken with a financial counsellor Applied for refinancing Spoken with a Debt Agreement Administrator Applied for hardship with creditors Other What has been the main cause of your financial difficulties? Unemployment/Loss of Income Relationship Breakdown Excessive Use of Credit Liabilities due to guarantees Gambling/speculation Adverse Legal Action Business Related Other Optional QuestionsDo you identify as Aboriginal or Torres Strait Islander?Please Select...YesNoWere you born overseas?Please Select...YesNoWhat Country?Please Select...AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweWhat languages do you speak at home?