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APPLICATION FOR CREDIT

 

Koopkrag limited is a authorised Financial Service Provider no 2763 and a Authorised Credit Provider in terms of section 40 of the National Credit Act 34 of 2005. The purpose of this application is to determine if the consumer qualifies for credit in accordance with the requirements of the National Credit Act,34 of 2005.

 

 

CONSUMER DETAILS
Title
First name
Surname
Christian names
Koopkrag account number
Identity number
Language :-
English
Afrikaans
Number of dependants
 
Marital Status
In community
Out of community
Divorced
Single
Widow / Widower
Residential address
Postal address
Code
Code
Tel no (H) ( )
Fax no ( )
Cellular phone number
E-mail address
Email Account : YES NO
Employer
Occupation / Title
Work address
Tel no (W) ( )
Service period
Y
M
Permanent
Temporary
Contract

 

SPOUSE DETAILS
Title
First name
Surname
Christian names
Identity number
Employer
Occupation / Title
Work address
Tel no (W) ( )
Service period
Y
M
Permanent
Temporary
Contract
Cellular phone number
E-mail address

 

 

AFFORDABILITY ASSESSMENT

NETT MONTHLY INCOME

MONTHLY EXPENSES
Applicant Salary
R
Bond Payments
R
Spouse's Salary
R
Vehicle Installments
R
Other Income - please specify:-
Credit Card Installments
R
1.
R
Schoolfees
R
2.
R
Short Term Insurance Premiums
R
3.
R
Medical Aid Contributions
R
 
Pension Fund Contributions
R
Policies
R
Groceries
R
Cellular Phone Accounts
R
Telkom Account
R
Rental Expenses
R
DSTV/Mnet
R
Municipal Accounts
R
Fuel
R
Other Expenses
R
TOTAL MONTHLY INCOME
R
TOTAL MONTHLY EXPENDITURE
R

 

ASSETS
LIABILITIES

Registered owner of property

     
Own
CC
 
Trust
Other
     
Registered in the name of
Bond Balance
R
Fixed Property (market value)
R
Loan accounts balance(s)
R
Furniture
R
Bank overdraft balance
R
Vehicles
R
Asset Finance balance
R
Investments
R
Surety
R
Other assets - please specify
Other Credit Facilities - please specify
1.
R
1.
R
2.
R
2.
R
3.
R
3.
R
           
TOTAL ASSET VALUE
R
TOTAL LIABILITIES
R

 

OTHER CREDIT FACILITIES
.....Credit Provider
..Account Number
....Monthly Installments
...Facility granted
1.
R
R
2.
R
R
3.
R
R
4.
R
R

 

REFERENCES – TWO RELATIVES (not residing with you)
Title
Initials
Title
Initials
Surname
Surname
Residential Address
Residential Address
Relationship
Relationship
Cell Number
Cell Number
Phone No (W)
Phone No (W)

 

CREDIT FACILITY APPLICATION
Please indicate the credit facility that you are applying for by ticking the appropriate box below :
 
Repayment Period
Deposit
Amount
"X"
1. Asset finance (motor vehicles, furniture etc.)
R
R
2. Short term loan
R
3. Bond
R

 

DOCUMENTATION
You have to attach the following documents to this application.
Please indicate, by ticking the appropriate box , which of the following documents have been included with this application.
YES
1. Copy of your identity document
2. Latest proof of income
3. Proof of residential address
4. Copy of your antenuptial contract (if applicable)

 

CREDIT APPLICANT DECLARATION
Please indicate your answer by ticking the appropriate box
YES
NO
1. Are you a juristic person?
2. Are you or have you ever been declared mentally ill by a High Court in South Africa ?
3 . Are you insolvent or is there any indication that your estate could be placed under provisional sequestration ?
4 . Are you currently under or have you ever applied for a debt review?
5 . Do you have a re – arranged agreement in place with any credit provider as a result of debt counselling?
6 . Do you have any dispute in process with a Credit Bureau ?
7 . Are you currently under an administration order in terms of section 74(1) of the Magistrate's Court Act ?

I / We declare that I / we have as part of this assessment process answered all the questions and requests for information fully and truthfully and that I / we understand the terms and conditions of section 89(3) of the Act.

 

I / We confirm that I / we am / are applying for this credit facility and understand the implications, consequences and risks attached to credit as explained to me / us.

 

I / We understand that the Credit Provider can refuse to grant this credit facility to me / us in terms of section 60(2) of the Act.

 

I / We hereby authorize the Credit Provider to obtain credit references and / or any other references from any Credit Bureau and / or person for the purpose of my / our application and pertaining to my/ our credit history.
Signed at
this
day of
Signature Consumer
Signature Consumer Spouse
(please fill in full name)
(please fill in full name)
 

 

 

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