National Credit Regulator

Online Assessment by Consumer for Debt Review in terms of section 86 of the
National Credit Act. Note: You make no commitment by simply filling out the form

Filling out the form:
** When entering figures/numbers, please DO NOT enter any COMMAS or
PUNCTUATIONS.
** When you have completed the form Press "PREVIEW" at the bottom, then
press "SEND". 
**IMPORTANT: Refer to the Information about Debt Review on your Left

ONLINE ASSESSMENT FOR DEBT REVIEW
(Note: This is not a Loan or Credit Card Application)

*Full Name and Surname:

If you are applying with a partner we will take his/her details when we have
received your application.

*Your ID Number:

*Gender (M/F):

*Marital status:

*Type of Marriage (COP,ANC,etc):

*Contact telephone no:

*Contact email:

*Name of employer:

*No. of Dependants supported in Household:

PART 2: INCOME

*NET Household Income (After all deductions):
R

PART 3: MONTHLY EXPENSES (Exluding Bonds and Car loans - you will list them
in PART 4 below)
Food:
R
Property Rental:
R
Municipal Rates (where property is owned):
R
Utilities (i.e water, electricity):
R
Transport (where essential for work):
R
Medical expenses:
R
Maintenance:
R
School Fees:
R
Telephone:
R
Clothing:
R
Insurance premiums:
R
Other essential living expenses:
R

PART 4: MONTHLY DEBT COMMITMENTS

    Creditor Name           Account No.              Tot. Debt            Monthly   
                                                                                                   Payment
1 
2 
3 
4 
5 
6 
7 
8 
9 
10
If you have more than 10 creditors, make a note of this below.

Reasons for being over indebted / Message:

To send your details to be assessed Press below button
(Note: This is not a Loan or Credit Card Application)

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