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Registration Form to claim from NCR FUND

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Registration Form to claim from NCR FUND Powered By Docstoc
					                                                                                                                  ANNEXURE 3
                                                 FORM C
                                           NCR FUND CLAIM FORM
Notes:
(i) A separate Form C must be completed for each consumer in respect of a claim for fees. More than one Form C may be submitted for
claims submitted at different times in respect of paragraphs 3(b), 3(c) and/or 3(d).
(ii) In order for this claim to be paid expeditiously, it is essential that all the required supporting documents accompany this form.
______________________________________________________________________________________

FORM C number: ___________

1. Particulars of Debt Counsellor

Name of debt counsellor: ___________________________________Registration number: _____________


2. Particulars of Consumer

Please provide the pre-approval number you obtained from the Fee Management Agency: ______________

Full name: _____________________________________________________________________________

Identity number: __________________________

Tel (w): ________________ Gross income p/m: R _____________ Household income p/m: R __________

Number of credit providers: ______________ Negotiated instalment p/m R__________________________

Have you charged or recovered any fees from the consumer (other than R50 application fee)? Yes __ No __

Status code currently recorded on NCR database for this consumer: B__C__D4__

Was the debt-rearrangement plan contested by credit providers in the Magistrate Court? Yes __ No __
If yes, attach a copy of court order and provide details of: Magistrate Court District: _____________________
Case number: _______________

Was the debt-rearrangement plan accepted by all credit providers in writing, without any Tribunal or court
intervention? Yes __ No __

3. Amount to be claimed from the NCR Fund

    #        Description                                                                                  Amount        Mark with
                                                                                                                        “X” where
                                                                                                                        applicable
             I confirm that the application for debt review was rejected in terms of                     R 100-00
    (a)      section 86(7)(a) and the NCR database has been updated to status
             code “B”.
    (b)      I confirm that the application for debt review was accepted in terms of                     R 500-00
             section 86(7)(c) and the consumer was assessed as over-indebted.
             The NCR database has been updated to status code “C” and a
             proposal has been sent to all the credit providers.
    (c)      I confirm that the debt re-arrangement plan was contested by some or                         R150-00
             all credit providers and the matter was referred to the Magistrate Court
             and a court order was granted. The NCR database has been updated
             to status code D4.

    The total amount I would like to claim from the NCR Fund is                                                        R

I certify that all the information contained herein is true and correct and I have complied with the
Terms and Conditions for claiming from the NCR Fund.

Debt Counsellor’s signature: _____________________________ Date: ____________________________

				
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Description: Registration Form to claim from NCR FUND