CCA online forms

CREDIT COUNSELLORS AUSTRALIA

Client Information Form

Complete your information, review the declaration and draw your signature.

1Personal and contact details
2Family and assets
3Employment
4Financial position and debts
5Review and sign

Step 1 of 5

Personal and contact details

The information in this form is confidential and will only be used for completing your Part IX Debt Agreement Application. Please fill out this form with accuracy. If you have any questions please contact your Case Manager. Once your submission is processed you will receive a copy in your email for your personal records. Credit Counsellors Australia l ABN 84 101 960 043 l Tel: 1300 003 328

Title

Given Name/s

Surname

Date of Birth (DD/MM/YYYY)

Other Name/s Known by / Maiden / Alias

Do you have a current driver's licence?

YES NO

Front

JPEG, PNG or PDF. Up to 12 MB per file; 48 MB in total.

Back

JPEG, PNG or PDF. Up to 12 MB per file; 48 MB in total.

File Upload

JPEG, PNG or PDF. Up to 12 MB per file; 48 MB in total.

Contact details

Mobile Number

Home Number

Work Number

Email Address

Current Residential Address

How long have you lived at this address? (i.e. 1 year and 3 months)

Do you own, are buying, renting, boarding or receiving free accommodation?

Is your postal address same as your current residential address?

Yes No

Previous Residential Address 1

Did you own or were you buying this property? (If you still own or are buying select yes).

Yes No

Previous Residential Address 2

Did you own or were you buying this property? (If you still own or are buying select yes).

Yes No

Please indicate the address of other investment property(ies) owned or purchased in the last 2 years

Step 4 of 5

Financial position and debts

Financial position

Have you been in a Debt Agreement or Bankruptcy in the last 15 years?

Yes No

When did you first have difficulties paying your debts? (Month/Year)

What circumstances led you to become unable to pay your debts?

Please provide a short statement supporting your financial/personal hardship, including the month and year of any major events. (i.e. I lost my job in March 2023, and since then, my debts have spiralled out of control, I separated from my partner in December 2023, which further negatively impacted my finances) *

What steps have you taken to manage your debts? (select all that apply)

Attempted a payment arrangement with creditors Attempted a consolidation loan Spoke to a financial counsellor Attempted refinancing

Have you applied to a lender for a formal hardship variation under the National Credit Code (i.e. reduced or postponed repayments due to illness, unemployment, or other financial difficulty) *

Yes No

Unsecured Debts

Please provide a list of your account details below for all your unsecured debts (i.e. credit cards, personal loans, payday loans, tax debts, disconnected utility accounts, medical bills, loans with friends/family, Zip Pay, Afterpay). (Add rows as needed)

Debt 1

Creditor's Name (i.e. ANZ)Account No. (i.e. 123-456 9876541)Account Type (i.e. credit card)Amount Owing ($) (i.e. $10,000)Sole / Joint account (i.e. sole)

Debt 2

Creditor's Name (i.e. ANZ)Account No. (i.e. 123-456 9876541)Account Type (i.e. credit card)Amount Owing ($) (i.e. $10,000)Sole / Joint account (i.e. sole)

Debt 3

Creditor's Name (i.e. ANZ)Account No. (i.e. 123-456 9876541)Account Type (i.e. credit card)Amount Owing ($) (i.e. $10,000)Sole / Joint account (i.e. sole)

Debt 4

Creditor's Name (i.e. ANZ)Account No. (i.e. 123-456 9876541)Account Type (i.e. credit card)Amount Owing ($) (i.e. $10,000)Sole / Joint account (i.e. sole)

Debt 5

Creditor's Name (i.e. ANZ)Account No. (i.e. 123-456 9876541)Account Type (i.e. credit card)Amount Owing ($) (i.e. $10,000)Sole / Joint account (i.e. sole)

Debt 6

Creditor's Name (i.e. ANZ)Account No. (i.e. 123-456 9876541)Account Type (i.e. credit card)Amount Owing ($) (i.e. $10,000)Sole / Joint account (i.e. sole)

Debt 7

Creditor's Name (i.e. ANZ)Account No. (i.e. 123-456 9876541)Account Type (i.e. credit card)Amount Owing ($) (i.e. $10,000)Sole / Joint account (i.e. sole)

Debt 8

Creditor's Name (i.e. ANZ)Account No. (i.e. 123-456 9876541)Account Type (i.e. credit card)Amount Owing ($) (i.e. $10,000)Sole / Joint account (i.e. sole)

Debt 9

Creditor's Name (i.e. ANZ)Account No. (i.e. 123-456 9876541)Account Type (i.e. credit card)Amount Owing ($) (i.e. $10,000)Sole / Joint account (i.e. sole)

Debt 10

Creditor's Name (i.e. ANZ)Account No. (i.e. 123-456 9876541)Account Type (i.e. credit card)Amount Owing ($) (i.e. $10,000)Sole / Joint account (i.e. sole)

Debt 11

Creditor's Name (i.e. ANZ)Account No. (i.e. 123-456 9876541)Account Type (i.e. credit card)Amount Owing ($) (i.e. $10,000)Sole / Joint account (i.e. sole)

Debt 12

Creditor's Name (i.e. ANZ)Account No. (i.e. 123-456 9876541)Account Type (i.e. credit card)Amount Owing ($) (i.e. $10,000)Sole / Joint account (i.e. sole)

Debt 13

Creditor's Name (i.e. ANZ)Account No. (i.e. 123-456 9876541)Account Type (i.e. credit card)Amount Owing ($) (i.e. $10,000)Sole / Joint account (i.e. sole)

Debt 14

Creditor's Name (i.e. ANZ)Account No. (i.e. 123-456 9876541)Account Type (i.e. credit card)Amount Owing ($) (i.e. $10,000)Sole / Joint account (i.e. sole)

Debt 15

Creditor's Name (i.e. ANZ)Account No. (i.e. 123-456 9876541)Account Type (i.e. credit card)Amount Owing ($) (i.e. $10,000)Sole / Joint account (i.e. sole)

Please attach a statement and/or invoice for each unsecured account you have listed above as a proof of debt

JPEG, PNG or PDF. Up to 12 MB per file; 48 MB in total.

Secured Debts

Please provide a list of your account details below for all your secured debts (i.e. mortgages, car loans, lines of credit against a property or business assets). (Add rows as needed)

Debt 1

Creditor's Name (i.e. ANZ)Account No. (i.e. 123-456 9876541)Account Type (i.e. mortgage)Amount Owing ($) (i.e. $500,000)Sole / Joint account (i.e. joint)

Debt 2

Creditor's Name (i.e. ANZ)Account No. (i.e. 123-456 9876541)Account Type (i.e. mortgage)Amount Owing ($) (i.e. $500,000)Sole / Joint account (i.e. joint)

Debt 3

Creditor's Name (i.e. ANZ)Account No. (i.e. 123-456 9876541)Account Type (i.e. mortgage)Amount Owing ($) (i.e. $500,000)Sole / Joint account (i.e. joint)

Debt 4

Creditor's Name (i.e. ANZ)Account No. (i.e. 123-456 9876541)Account Type (i.e. mortgage)Amount Owing ($) (i.e. $500,000)Sole / Joint account (i.e. joint)

Debt 5

Creditor's Name (i.e. ANZ)Account No. (i.e. 123-456 9876541)Account Type (i.e. mortgage)Amount Owing ($) (i.e. $500,000)Sole / Joint account (i.e. joint)

Debt 6

Creditor's Name (i.e. ANZ)Account No. (i.e. 123-456 9876541)Account Type (i.e. mortgage)Amount Owing ($) (i.e. $500,000)Sole / Joint account (i.e. joint)

Please attach a statement and/or invoice for each secured account you have listed above as a proof of debt

JPEG, PNG or PDF. Up to 12 MB per file; 48 MB in total.

Non-Provable Debts

If you have any non-provable debts such as rental goods, speeding fines, traffic infringements, FEE-HELP / HECS, current utility arrears, child support debt, please provide details below (Add rows as needed)

Debt 1

Creditor's Name (i.e. radio rentals)Account No. (i.e. 456541)Account Type (i.e. rental of a laptop)Amount Owing ($) (i.e. $2,000)

Debt 2

Creditor's Name (i.e. radio rentals)Account No. (i.e. 456541)Account Type (i.e. rental of a laptop)Amount Owing ($) (i.e. $2,000)

Debt 3

Creditor's Name (i.e. radio rentals)Account No. (i.e. 456541)Account Type (i.e. rental of a laptop)Amount Owing ($) (i.e. $2,000)

Debt 4

Creditor's Name (i.e. radio rentals)Account No. (i.e. 456541)Account Type (i.e. rental of a laptop)Amount Owing ($) (i.e. $2,000)

Debt 5

Creditor's Name (i.e. radio rentals)Account No. (i.e. 456541)Account Type (i.e. rental of a laptop)Amount Owing ($) (i.e. $2,000)

Debt 6

Creditor's Name (i.e. radio rentals)Account No. (i.e. 456541)Account Type (i.e. rental of a laptop)Amount Owing ($) (i.e. $2,000)

Please attach a statement and/or invoice for each non-provable account you have listed above as a proof of debt

JPEG, PNG or PDF. Up to 12 MB per file; 48 MB in total.