Submitting a Financial Statement

In order for us to fully understand your current financial status, we need to know more about your financial situation. As such please complete the following survey, filling in all possible details.

Once you have completed this survey we will send you an automated response to confirm we have received it. Once we have reviewed this survey we will be able to contact you to discuss the matter further.

If you would like to update your details after you have submitted this survey or have a question, feel free to contact us on 1300 799 511 quoting your reference.

Please try to answer all questions. If it does not apply to you, put N/A and the reason it does not apply.

    Case Number


    Personal Details


    First name

    Middle Name

    Last Name

    Other names(Nicknames, Previous Names)

    Date of birth


    Street Address/PO Box




    Personal Email Address

    Mobile Phone Number

    Home Phone Number

    Marital Status

    How many dependents do you have in your care?

    What are their ages?

    Employment Details

    Are you currently employed?

    Place of Employment


    Street Address




    Work Email Address

    Contact Number

    Email Address

    Do you own a company?

    Company Name

    Is the company registered? If yes, ABN/ACN number?

    If unemployed, what is the length of your unemployment?

    Will you be starting employment in the near future?

    What is the name of your previous employer?

    Date of last employment

    Contact Number

    Income Details

    Please attach a copy of your most recent income statement (e.g., tax assessment, payslips, bank statements, etc...)

    What income do you receive after tax?

    What is the nature of this income (e.g. wages, salary, commission, benefits, etc...)?

    If you are not working, what is your primary source of income (e.g. sole parent benefit, disability pension, etc...)? If so, please explain.

    Do you have any other sources of income (e.g. part-time work, casual, dividends, rents, etc...)? If so, from what source and how much?

    Asset Details

    Do you currently own or plan to buy any land or property? If yes, please provide details

    Do you currently own or plan to buy a motor vehicle?




    Is the motor vehicle registered?

    Registration Number

    Driver's Licence Number

    Is the vehicle subject to finance?

    If yes, who is the financier?

    How much is owing?

    Vehicle value?

    Insurance Company

    Policy Number

    Insurance Broker

    Do you have any personal property or assets not previously mentioned? If so, please give details (e.g., include investments, debentures, shares, etc...)


    Please give details of your expenses calculated on a weekly basis and attach copies of supporting documentation(e.g., bills, bank statements, receipts, etc…)


    Municipal & Water Rates



    Utilities (Gas/Electricity etc...)




    Insurance (Motor/House/Contents)


    Credit Card Repayments (Give details of each loan and balance owing)

    Loan Repayments (Give details of each loan and balance owing)

    Transportation Expenses (including public transport, vehicle registration, parking, maintenance and fuel)

    Other Expenses

    Are there any other unpaid debts/fines against you? If so, please provide the following details:

    Contact name and nature of money owed

    Street Address




    Do you have an offer to pay this debt and if so, when and how often can payments be made? Please provide the details below, as well as any other relevant information.

    Terms and Conditions

    I certify that I have read and accept the Terms and Conditions

    Attach Proof of income here