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Liability Details
Surety
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No
Surety Description
Guarantor
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Guarantor Description
Co-Debtor
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Co-Debtor Description
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Payment History
Are You Currently Under Debt-Review?
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No
Do you have a re-arrangement in place with any credit provider as a result of debt Counselling?
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No
Are you currently under administration order or Curator Bonus?
Yes
No
Have you ever been under administration order?
Yes
No
Have you ever had a judgment against you to your knowledge?
Yes
No
Do you have a dispute in progress with a credit bureau?
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No
Are you currently under sequestration order?
Yes
No
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Finance Details
Agreement
Installment Sale Agreement
Lease Agreement
Buy-Back
Repayment Period
6 Months
12 Months
18 Months
24 Months
30 Months
36 Months
42 Months
48 Months
54 Months
60 Months
72 Months
78 Months
84 Months
96 Months
66 months
90 months
Payment Frequency
Monthly
Annually
Quarterly
Bi-Annually
Interest Rate: %
Rate Indicator
Linked
Fixed
Residual / Balloon Value: %
Deposit
Finance Initiation Fees
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Pay in Advance
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Relative Details
First Name
Surname
Relation
Aunt
Brother
Brother in Law
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Daughter
Father
Father in Law
Friend
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Mother
Mother in Law
Sister
Sister in Law
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Contact Number
Relative Address 1
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Relative City
Relative Suburb
Postal Code
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Banking Details
