Online Application

Personal Information

Full Names

Surname

ID/Passport number

I hereby give consent for my debt review application and/or relating documents to debt review be sent via email as stated below:

Email Address

Cellphone Number Only use digits (0-9). For example: 555 7788 or 011 555 7788.

Work Number Only use digits (0-9). For example: 555 7788 or 011 555 7788.

Gender

Marital Status

Number of Dependents Only use digits (0-9).

Ages of Dependents Only specify if you have dependents.

Physical Address

City

Province

Postal Code Only use digits (0-9).

Employer Details

Employer

Job Title

Work Number Only use digits (0-9). For example: 555 7788 or 011 555 7788.

Employer Address

City

Province

Postal Code Only use digits (0-9).

Spouse Information (Compulsory if Married COP or Traditional)

Full Names

Surname

ID/Passport number

Cellphone Number Only use digits (0-9). For example: 555 7788 or 011 555 7788.

Work Number Only use digits (0-9). For example: 555 7788 or 011 555 7788.

Spouse's Employer Details

Employer

Job Title

Work Number Only use digits (0-9). For example: 555 7788 or 011 555 7788.

Employer Address

City

Province

Postal Code Only use digits (0-9).

Budget Details: Income

Gross Income [Main Applicant] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

Gross Income [Spouse] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

Overtime [Main Applicant] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

Overtime [Spouse] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

Commission (average 6 months) [Main Applicant] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

Commission (average 6 months) [Spouse] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

Total Income [Main Applicant] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

Total Income [Spouse] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

Budget Details: Salary Deductions

PAYE [Main Applicant] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

PAYE [Spouse] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

UIF [Main Applicant] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

UIF [Spouse] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

Pension/Provident Fund [Main Applicant] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

Pension/Provident Fund [Spouse] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

Medical Aid [Main Applicant] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

Medical Aid Fund [Spouse] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

Other Deductions [Main Applicant] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

Other Deductions [Spouse] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

Total Deductions [Main Applicant] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

Total Deductions [Spouse] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

Any other payslip deductions will be checked on the payslip provided by the client.

Nett Salary (after deductions) [Main Applicant] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

Nett Salary (after deductions) [Spouse] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

Budget Details: Living Expenses

Groceries (incl. food, fruit, veg) [Main Applicant] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

Groceries (incl. food, fruit, veg) [Spouse] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

Rent (not bond) [Main Applicant] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

Rent (not bond) [Spouse] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

Water & Electricity [Main Applicant] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

Water & Electricity [Spouse] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

Rates & Levies [Main Applicant] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

Rates & Levies [Spouse] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

School Fees/Creche Fees [Main Applicant] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

School Fees/Creche Fees [Spouse] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

All Insurances [Main Applicant] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

All Insurances [Spouse] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

Petrol/Transport [Main Applicant] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

Petrol/Transport [Spouse] Main Applicant Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

Telephone/Internet [Main Applicant] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

Telephone/Internet [Spouse] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

Other (please specify) [Main Applicant] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

Other (please specify) [Spouse] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

Total Expenses [Main Applicant] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

Total Expenses [Spouse] Only use digits (0-9). For example: 12000, 1,200, 1200.00 or 1,200.00.

Reason for Over-Indebtedness

Specify Reasons

DECLARATION

I hereby declare that the above information is for myself, and it is true. I give consent to ExitDebt to obtain my credit report via a registered credit bureau in purposes of the debt review assessment.

Agree

Disagree

Documents

Copy of ID/Passport

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Jpg/Png/PDF Only! Document must not exceed 20MB.

Copy of Spouse's ID/Passport

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Jpg/Png/PDF Only! Document must not exceed 20MB.

Copy Latest Payslip

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Jpg/Png/PDF Only! Document must not exceed 20MB.

Copy of Spouse's Latest Payslip

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Jpg/Png/PDF Only! Document must not exceed 20MB.

Main Applicant Signature |

Use your mouse or finger to sign.

Spouse's Signature |

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