Personal Information
Name
First Last
ID Number
Race
Gender
Contact Details
Tel. (Home)
Tel. (Work)
Cell Phone Number
Email Address
Address
Period Residing at Address
Your Employment Details
Employer
Occupation
Period Employed
Work Address
Owner / Tenant Property
- Owner
- Tenant
Marital Status
- Single
- Married - Community of Property
- Married - Anti-Naptual Contract
- Divorced
Spouse / Partner's Information
Name
First Last
ID Number
Gender
Spouse Contact Details
Tel. (Home)
Tel. (Work)
Cell Phone Number
Email
Spouse Employment Details
Employer
Occupation
Period Employed
Work Address
Dependant Details
Number Of Dependants
Dependant 1: Name - Age - Gender
Dependant 2: Name - Age - Gender
Dependant 3: Name - Age - Gender
Dependant 4: Name - Age - Gender
Dependant 5: Name - Age - Gender
Dependant 6: Name - Age - Gender
Dependant 7: Name - Age - Gender
Dependant 8: Name - Age - Gender
Dependant 9: Name - Age - Gender
Next of kin, name
Next of kin relationship
Next of kin contact number

Save and Continue Later

Save and Continue Later

Save and Continue Later

Save and Continue Later

Creditor Information
Creditor 1 Name*
Account Number
Balance*
Instalment*
Creditor 2 Name
Account Number
Balance
Instalment
Creditor 3 Name
Account Number
Balance
Instalment
Creditor 4 Name
Account Number
Balance
Instalment
Creditor 5 Name
Account Number
Balance
Instalment
Creditor 6 Name
Account Number
Balance
Instalment
Creditor 7 Name
Account Number
Balance
Instalment
Additional Comments / Questions
Pleas note that:
- On receipt of this application the Debt Counsellor will draw your credit report and advise all relevant credit providers and registered credit bureaus that you have applied for debt review.
- All payments need to be made directly to the Payment Distribution Agent, DC Partner. Your Debt Counsellor will provide you with these banking details. No cash payments may be made to or accepted by Debt Review Centre, any of its representatives or staff. All payments are to be made ONLY to the Payment Distribution Agent, DC Partner. DRC rejects liability should any cash payments be made to DRC, or any of its representatives or staff.

Please send us copies, photographs or scans of the following documents:
Signature

Save and Continue Later

Application By Consumer for Debt Review in Terms of Section 86 of The National Credit Act 34 of 2005

Personal Information