Debt Consolidation Form

ENQUIRY DATE:

Number of applicants*

Referred by?

Referred by: name?

Reason for loan

Debt consolidation (adding debts together)
Car loan
Renovations
Holiday
Other

Other Please Specify*

Amount you are looking for?

Minimum amount required*

Maximum amount required*

debts you would like to repay are

Please list all debt below, click on the + icon to add more fields.

We recommend you check to see if any early break costs or penalties to pay off any debt early.

Debt Type	Monthly payment or card limit	Approx balance	Interest rate if known

Do you own a home?

Yes
No

What is your address?

What is the total amount of lending you have with the bank?

What do you think your house is worth?

Have you approached the bank for a debt consolidation?

Yes
No

What was the outcome?

In the last 3 months have you had any late payments on loans, Hp’s etc or been over your card limits on finance cards?

Yes
No

Please specify

What can you afford to pay on new loan repayments per week as a guide.

Income

Section Break

Do you have children?`

Yes
No

If Yes. How many and their names & ages?

Do you pay or receive child support?`

Yes
No

How Often?

Child support amount

Do you have any other debts that will remain as is or cards and their limits?

Please list all debt below, click on the + icon to add more fields.

Debt Type	Monthly payment or card limit	Approx balance	Interest rate if known

What make, model and year is you car if known?

As some places can use your car as security depending on age, this would lower your interest rate.

How many KM's

Does it have a current warrant and rego?

What do you pay in rent / board or mortgage payments per week?

INSURANCE

In the event of death or not working due to accident or illness

Would you like us to help you with some options to explore this type of cover?

Yes
No

have either of you vaped or smoked in the last 12 months?

Yes Vaped
Yes Smoked
No

Have any of the people that are applying in last 7 years had any Defaults &/or Collections - e.g. Baycorp /Financial Institution

Yes
No

Details

Have they been Paid?

Yes
No

Year was paid*

In the last 3 months have you had any unarranged over draft fees, or dishonours on any of your personal bank accounts?

Yes
No

If after assessment of this initial enquiry form, Brenda feels a loan approval would be unlikely, Brenda will advise you of this and what options you may have for the future.

Once you have completed the form, Click SUBMIT. We will contact you to discuss your options and arrange an initial meeting.

Before proceeding, please read our Privacy Statement below.

Privacy Statement

1. The personal information collected in this Initial Enquiry Form will be used to determine initial eligibility for potential home and/or personal loans and if necessary gain a credit check assessment.

2. Brenda Nom Mortgage and Insurances Limited undertake to keep this information confidential and secure. This information may be in paper format and/or electronic files and/or held remotely in secure electronic storage systems.

3. I am required to keep these records on file for a period of 7 years or longer whether or not this engagement terminates.

4. Besides our staff we may share this information with potential loan providers and credit checking agencies.

5. Providing some information is optional. If you choose not to enter financial information we will be unable to determine loan eligibility.

6. You have the right to ask for a copy of any personal information we hold about you and to ask for it to be corrected if you think it is wrong. If you like to ask for a copy of your information or have it corrected please contact us at info@brendanom.co.nz or 03 2149292 or 12 Don Street, Invercargill.

Privacy Waiver & Service Agreement

I / We confirm I / We have read and understood the ‘Privacy Statement’ and authorise Brenda Nom Mortgage and Insurance Limited to complete a Credit Check Assessment if required before further assessment.