YOUR PERSONAL DETAILS
Your Full Name *
Drivers Licence Number
Number of Dependants *
-- Please select --
1
2
3
4
5+
Age of Dependants
Phone Number - Home
Phone Number - Mobile
Phone Number - Work
Your Email Address *
Residential Status *
-- Please select --
Owner
Renting
Boarding
Paying Mortgage
Living With Parents
Unit Number and / or Street Number
Street Name
Suburb, State and Postcode
YOUR EMPLOYMENT DETAILS
Your Employment Status *
-- Please select --
Full-Time Employed
Part-Time Employed
Self-Employed
Unemployed
Retired
Name of Current Employer
Occupation
Date Commenced Employment
YOUR HOUSEHOLD INCOME
I Receive My Income:
-- Please select --
Weekly
Fortnightly
Monthly
After Tax Salary
Centrelink Payments
Family Tax Benefit
Child Support Received
Rental Income or Board Income
Other Income
Total Household Income *
YOUR REGULAR EXPENDITURE
My Expenditures Are:
-- Please select --
Weekly
Fortnightly
Monthly
Mortgage or Rental Payments
Mortgage Interest and Charges
Body Corporate Fees
Council Rates
Electricity
Gas
Water
Internet
Pay-TV
Home Phone
Mobile
Car Insurance
Home and Contents Insurance
Health Insurance
Groceries
Clothing and Shoes
Health (Insurance and Medical)
Entertainment
Personal Care
Life Insurance
Pet Expenditure
Other (Subscriptions, Sports, Hobbies)
Vehicle Costs (Fuel)
Vehicle Costs (Registration)
Vehicle Costs (Insurance)
Public Transport (Train, Taxi, Ferry)
Other Transport Expenses
Child Education and / or Childcare
Self-Education (University, TAFE)
Other (Child Support Payments)
Total Living Expenditure *
DETAILS OF YOUR ASSETS
Your Assets
-- Please select --
Motor Vehicle
Investment Property
Residential Property
Savings
Superannuation
Household Furniture
Tools of Trade
Other
Provide Details
Your Assets
-- Please select --
Motor Vehicle
Investment Property
Residential Property
Savings
Superannuation
Household Furniture
Tools of Trade
Other
Provide Details
Your Assets
-- Please select --
Motor Vehicle
Investment Property
Residential Property
Savings
Superannuation
Household Furniture
Tools of Trade
Other
Provide Details
Your Assets
-- Please select --
Motor Vehicle
Investment Property
Residential Property
Savings
Superannuation
Household Furniture
Tools of Trade
Other
Provide Details
Your Assets
-- Please select --
Motor Vehicle
Investment Property
Residential Property
Savings
Superannuation
Household Furniture
Tools of Trade
Other
Provide Details
Your Assets
-- Please select --
Motor Vehicle
Investment Property
Residential Property
Savings
Superannuation
Household Furniture
Tools of Trade
Other
Provide Details
Your Assets
-- Please select --
Motor Vehicle
Investment Property
Residential Property
Savings
Superannuation
Household Furniture
Tools of Trade
Other
Provide Details
Your Assets
-- Please select --
Motor Vehicle
Investment Property
Residential Property
Savings
Superannuation
Household Furniture
Tools of Trade
Other
Provide Details
DETAILS OF YOUR OUTSTANDING DEBTS
Your Outstanding Debts
-- Please select --
Investment Property Loan
Home Mortgage
Personal Loan(s)
Credit Card(s)
Other
Provide Details
Your Outstanding Debts
-- Please select --
Investment Property Loan
Home Mortgage
Personal Loan(s)
Credit Card(s)
Other
Provide Details
Your Outstanding Debts
-- Please select --
Investment Property Loan
Home Mortgage
Personal Loan(s)
Credit Card(s)
Other
Provide Details
Your Outstanding Debts
-- Please select --
Investment Property Loan
Home Mortgage
Personal Loan(s)
Credit Card(s)
Other
Provide Details
Your Outstanding Debts
-- Please select --
Investment Property Loan
Home Mortgage
Personal Loan(s)
Credit Card(s)
Other
Provide Details
YOUR REPAYMENT OFFER
How Much Will You Pay? *
Frequency of Payments *
-- Please select --
Weekly
Fortnightly
Monthly
1st Payment Date *
Preferred Payment Method *
-- Please select --
Online Direct Debit
Telephone Direct Debit
BPAY
Electronic Funds Transfer
Bank Deposit
Online Debit Card
Other Comments or Questions
ATTACH SUPPORTING DOCUMENTATION
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VERIFICATION STATEMENT
The Information I Have Supplied Is True and Correct
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Yes
No
Prove you're not a robot *