Bankruptcy Application Form - Revive Financial

Contact Details

Full Name*

First Last

Have you previously gone by any other name?

First Last

Email*

Phone*

Date of Birth

Living Arrangements

Marital Status*

Spouse/Partners Name

First Last

Dependants

Dependant First Name	Dependant Last Name	Dependant Age

Current Residence

Current Residency*

How long at current Address?*

Current Residential Address*

Street Address Suburb State Post Code

Previous Residence

Previous Residential Address 1

Street Address Suburb State Post Code

How long at previous address?

Did you own this property?

If 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?

If sold, what year was it sold?

Personal Reference

Please 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 Details

Employment Status*

Name 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*

Address of Employment

Street Address Suburb State Post Code

Time Unemployed*

Name of previous employer (company name)

Debt Overview

I have Secured Debt.*

Secured Debt includes any finance secured over an asset (e.g. Home Loans, Car Loans, Leased Equipment or Rental Goods).

Secured Debt*

Type of Debt...	Creditor Name	Card/Account/Reference Number	Repayment Amount	Repayment Frequency	Asset Value	Joint?	Hardship?	Amount Owing

I have Unsecured Debt.*

Please include all Unsecured Debt (Credit Cards, Store Cards, Personal Loans, Overdraft Facilities, ATO Debt & Overdue or Disconnected Bills).

Unsecured Debt*

Type of Debt...	Creditor Name	Card/Account/Reference Number	Repayment Amount	Repayment Frequency	Age of Debt	Joint?	Hardship?	Amount Owing

Value in Assets Owned Outright

These are assets you own outright. In other words, you don't owe any money for the following items.

Cash Savings

Joint Owned?

Property (Please advise below)

Joint Owned?

Vehicles (Please advise below)

Joint Owned?

Business Tools and Assets

Joint Owned?

Investments/Shares/Managed Funds

Joint Owned?

Furniture and Household Items

Joint Owned?

Vehicles Owned

Make	Model	Year	Transmission	Vehicle Registration Number	Is this vehicle for sale?

Properties Owned

If you indicated you owned property in the table above, please provide details here.

Properties Owned

Property Address	Property Value	Is the Property for Sale?

Your Weekly Income

Please enter Net amount after tax.

Wages/Salary (after tax) Job 1

Wages/Salary (after tax) Job 1 - you

Wages/Salary (after tax) Job 1 - spouse

Wages/Salary (after tax) Job 2

Wages/Salary (after tax) Job 2 - you

Wages/Salary (after tax) Job 2 - spouse

Centrelink Benefits

Centrelink Benefits - you

Centrelink Benefits - spouse

Child Support/Maintenance Received

Child Support/Maintenance Received - you

Child Support/Maintenance Received - spouse

Rental Income (incl board, contributions from children)

Rental Income - you

Rental Income - spouse

Business Income

Business Income - you

Business Income - spouse

Other Income

Other Income - you

Other Income - spouse

Total Weekly Income

Total Weekly Income - you

Total Weekly Income - spouse

Business Dealings

Have you operated a business in the past 5 years?

Have you been a director or had a management role in a company any time in the last 2 years?

Company Name

Trading Name

Company Activity

Date you started operating

Registered Company Address

Street Address Suburb State Post Code

Do you have an interest in a Trust?

Trust Name

Trustee's Name

Trustee's Address

Street Address Suburb State Post Code

Financial Details

Please 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 History

Have you declared Bankruptcy or entered into any other kind of Insolvency Agreement?*

What year was it finalised/terminated?*

Are you currently up-to-date with payments to your creditors?

Last able to pay your debts as they fell due?*

Your Insolvency

What 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?

Professional Advisors

Please 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 Support

Do you expect to receive any Child Support?

Name of person paying Child Support

Expected Child Support Amount

Child Support Payment Received

Do you expect to pay any child support?

Name of person receiving child support

Child Support payment amount

Child Support Payment Frequency

Family Law Proceedings

Are you involved in any family law, property or spousal maintenance orders/agreements?

Name of other person involved

First Last

Date of court proceeding

Legal Actions

Are you involved in any legal action with creditors?

Which creditors?

Proceeds of Crime

Are you under any investigation regarding proceeds of crime?

Insurance

Do you have Private Health Insurance?

Do you have life insurance?

What amount are you insured for?

Salary Sacrifice

Has your salary now, or in the last 2 years, been subject to a salary sacrifice arrangement?

Please provide details:

Superannuation

Superannuation Fund Company Name

Current Super Balance

Amount paid per week by employer

Have you made a lump sum contribution to your Super in the last 5 years?

What was the lump sum amount?

Has anyone (other than your employer) made any super contributions on your behalf?

Have you received a super payout in the last 5 years?

Do you expect to receive a super payout in the next 3 years?

Other Benefits

Are you, or any member of your family, provided with any benefits from another person? (Rent, car, etc)

Please provide details

Bank Accounts

It is important to list all bank accounts in your name. Even those with $0 balances.

Bank Name	BSB	Account Number	Account Type	Current Balance	Is this a Joint Account?

Tax Refund

Do you expect to receive a tax refund?

Expected Refund Amount

Shares

Do you own any shares?

Total value of shares

Please provide details of your shares

Investments

Do you own any other investments?

Total Investment Value

Please provide details on your investments

Money Owed

Does anyone owe you money?

How much are you owed?

Interest in Deceased Estate

Do you have an interest in any deceased estate at present?

Expected Amount

Sale, Transfer or Gift of Assets

Have you sold, transferred or gifted any assets to any person in the past 5 years?

Value of asset sold, transferred or gifted

Please provide details of transaction (who, what, date, etc)

Assets held by others

Do you have any assets that are held by others?

Value of asset being held

Please provide details on asset being held

Contributions to Assets

Have you contributed towards any assets owned by others in the past 5 years?

Creditor Payments

Have you paid more than $1000 to any creditor in the past year over and above normal repayments?

Amount of additional payment

Please provide details about additional payment

Passport Information

Passport Number

Passport Expiry Date

Country of Issue

Optional Questions

Do you identify as Aboriginal or Torres Strait Islander?

Were you born overseas?

What Country?

What languages do you speak at home?

Bankruptcy

Personal Insolvency

Company Liquidation

Voluntary Administration

Tax Debt

Director Advice

Turnaround & Restructuring

Contact Details

Living Arrangements

Current Residence

Previous Residence

Personal Reference

Employment Details

Debt Overview

Value in Assets Owned Outright

Vehicles Owned

Properties Owned

Your Weekly Income

Business Dealings

Financial Details

Insolvency History

Your Insolvency

Professional Advisors

Child Support

Family Law Proceedings

Legal Actions

Proceeds of Crime

Insurance

Salary Sacrifice

Superannuation

Other Benefits

Bank Accounts

Tax Refund

Shares

Investments

Money Owed

Interest in Deceased Estate

Sale, Transfer or Gift of Assets

Assets held by others

Contributions to Assets

Creditor Payments

Passport Information

Optional Questions

Need Help?