Contact DetailsFull Name* First Last Have you previously gone by any other name? First Last Email* Phone*Date of Birth DD slash MM slash YYYY 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 1 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?Previous Residential Address 2 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...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 I have Unsecured Debt.*Please include all Unsecured Debt (Credit Cards, Store Cards, Personal Loans, Overdraft Facilities, ATO Debt & Overdue or Disconnected Bills).Please Select...YesNoUnsecured 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 OwnedMakeModelYearTransmissionVehicle Registration NumberIs 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 - spouseBusiness DealingsHave you operated a business in the past 5 years?Please Select...YesNoHave you been a director or had a management role in a company any time in the last 2 years?Please Select...YesNoCompany NameTrading NameCompany ActivityDate you started operating MM slash DD slash YYYY Registered Company Address Street Address Suburb State Post Code Do you have an interest in a Trust?Please Select...YesNoTrust NameTrustee's NameTrustee's Address Street Address Suburb State Post Code Financial 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?* DD slash MM slash YYYY 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 Professional AdvisorsPlease provide the contact details of your preferred professional advisors.Accountants Firm Name*Accountants Phone*Contact Person* First Last Accountants Firm Address* Street Address Suburb State Post Code Solicitors Firm Name*Solicitors Phone*Contact Person* First Last Solicitors Firm Address* Street Address Suburb State Post Code Child SupportDo you expect to receive any Child Support?Please Select...YesNoName of person paying Child SupportExpected Child Support AmountChild Support Payment ReceivedPlease Select...WeeklyFortnightlyMonthlyDo you expect to pay any child support?Please Select...YesNoName of person receiving child supportChild Support payment amountChild Support Payment FrequencyPlease Select...WeeklyFortnightlyMonthlyFamily Law ProceedingsAre you involved in any family law, property or spousal maintenance orders/agreements?Please Select...YesNoName of other person involved First Last Date of court proceeding DD slash MM slash YYYY Legal ActionsAre you involved in any legal action with creditors?Please Select...YesNoWhich creditors?Proceeds of CrimeAre you under any investigation regarding proceeds of crime?Please Select...YesNoInsuranceDo you have Private Health Insurance?Please Select...YesNoDo you have life insurance?Please Select...YesNoWhat amount are you insured for?Salary SacrificeHas your salary now, or in the last 2 years, been subject to a salary sacrifice arrangement?Please Select...YesNoPlease provide details:SuperannuationSuperannuation Fund Company NameCurrent Super BalanceAmount paid per week by employerHave you made a lump sum contribution to your Super in the last 5 years?Please Select...YesNoWhat was the lump sum amount?Has anyone (other than your employer) made any super contributions on your behalf?Please Select...YesNoHave you received a super payout in the last 5 years?Please Select...YesNoDo you expect to receive a super payout in the next 3 years?Please Select...YesNoOther BenefitsAre you, or any member of your family, provided with any benefits from another person? (Rent, car, etc)Please Select...YesNoPlease provide detailsBank AccountsBank AccountsIt is important to list all bank accounts in your name. Even those with $0 balances.Bank NameBSBAccount NumberAccount TypeCurrent BalanceIs this a Joint Account? Please Select...YesNo Tax RefundDo you expect to receive a tax refund?Please Select...YesNoExpected Refund AmountSharesDo you own any shares?Please Select...YesNoTotal value of sharesPlease provide details of your sharesInvestmentsDo you own any other investments?Please Select...YesNoTotal Investment ValuePlease provide details on your investmentsMoney OwedDoes anyone owe you money?Please Select...YesNoHow much are you owed?Interest in Deceased EstateDo you have an interest in any deceased estate at present?Please Select...YesNoExpected AmountSale, Transfer or Gift of AssetsHave you sold, transferred or gifted any assets to any person in the past 5 years?Please Select...YesNoValue of asset sold, transferred or giftedPlease provide details of transaction (who, what, date, etc)Assets held by othersDo you have any assets that are held by others?Please Select...YesNoValue of asset being heldPlease provide details on asset being heldContributions to AssetsHave you contributed towards any assets owned by others in the past 5 years?Please Select...YesNoCreditor PaymentsHave you paid more than $1000 to any creditor in the past year over and above normal repayments?Please Select...YesNoAmount of additional paymentPlease provide details about additional paymentPassport InformationPassport NumberPassport Expiry Date DD slash MM slash YYYY Country of IssuePlease 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 GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweOptional 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?
