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Form - Summary Instalment Order application by rte12803

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									                 Summary Instalment Order – Information


The Summary Instalment Order (SIO) is an alternative to bankruptcy. The Insolvency Act 2006
specifies the information that must be provided by you and the matters that must be
considered by the Official Assignee. Should you decide to submit your application it will be
carefully considered by the Official Assignee and may or may not be accepted. You will be
notified as soon as a decision has been made, which is expected to be within 10 working days
of receipt of the completed application.

Whilst the normal term of an SIO is up to 3 years, the Order may be formally varied or
discharged by the Official Assignee during this period. During the course of the SIO there will
be a restriction on your ability to incur credit.

A Filing Fee will be charged for Summary Instalment Order applications, in addition to any costs
payable for the administration of the Order. These costs will be deducted from any payments
and/or asset realisations made.

If you require further information before making the decision to submit your application, you
can access a range of information on our website (www.insolvency.govt.nz) or contact a budget
advisor, solicitor or accountant for advice. If you wish to proceed your next step is to contact
someone who you want to act as a Supervisor for your SIO. You may nominate someone you
know, or you may wish to choose someone who is already experienced in this role. A list of
current SIO Supervisors is available from our website.


Please post your completed application form to:
  Insolvency and Trustee Service
  Private Bag 4714
  Christchurch 8140


      Important

If you choose to submit your application, then once verification has been received
any decision by the Official Assignee to accept your application will be legally
binding on you. Prior to this decision being made you may choose to phone our Contact
Centre on 0508 467658 to withdraw your application.
                                                            SIO Proposal
                                         Pursuant to section 341 Insolvency Act 2006
 A Summary Instalment Order is a legally binding order made by the Official Assignee that governs how and to what
 extent you will repay your debts over a period of up to three years. The information provided in this section will form the
 basis of any Order that is made by the Official Assignee. You need to specify in this section of your application the
 amount and frequency of the repayments you are proposing, and details of any of your assets that you are proposing be
 sold towards meeting your debts. If you intend to repay your debts in less than 3 years, please specify this in the
 Comments box, or alternatively if you wish to apply for a longer period (up to 5 years) then you must give reasons for
 this proposed extension.

Applicant Details
Last Name:

First Name(s):

Preferred Title:      Mr    Mrs        Ms     Miss    Other (please specify):

Date of Birth:     Day:                  Month:                    Year:


Full residential address:   Street number & name:

                            Suburb:

                            City:                                                       Postcode:

                            Country:

Email address:

Daytime Phone Number:

Mobile Phone Number:

Occupation:


Proposal Details
   I propose to repay the full amount of my debts OR

   I propose to repay                 cents in the dollar

Please enter the proposed amount of money you wish to repay in each instalment. NZ$
                                                             Every one / two weeks / months
Please enter the proposed frequency of each instalment:
Do you propose to sell any assets as part of your Summary Instalment Order?            Yes          No

Please describe any assets that you would propose to sell as part of your Summary Instalment Order. If you wish to list
additional assets please provide details on a separate sheet of paper and attach it to this page.

 Asset Description (include registration number if applicable)              Estimated Resale Value       Amount Owed (e.g. HP)
                                                                                $                        $
                                                                                $                        $
                                                                                $                        $
                                                                                $                        $
                                                                                $                        $

Have any of your debts been guaranteed by any person? If so, please list the debts and the name and address of the
guarantor in the box below:
                                                SIO Proposal
                                                      Page 2
Comments.

Please provide any other information that you believe is relevant to your proposal. Summary Instalment Orders typically
last for 3 years. If you propose to repay your debts in less than 3 years, please specify here. If you wish the Official
Assignee to consider an extension of the period to up to 5 years, please specify here and state your reasons.




                                         SIO Supervisor Selection

To apply for a Summary Instalment Order, you must nominate a Summary Instalment Order
Supervisor. It is your responsibility to locate and contact the Summary Instalment Order Supervisor
of your choice. A list of Supervisors is available on our website (www.insolvency.govt.nz).

Before your application for a Summary Instalment Order can be accepted, the Supervisor you select
must provide their consent to be your Supervisor, and must be vetted by ITS. If for any reason the
Official Assignee does not accept your choice of SIO Supervisor, you will be able to select an
alternative Supervisor for consideration.

Please provide the contact details for your proposed Supervisor.


Name of proposed Supervisor:

Email or postal address of Supervisor:

Daytime phone number of Supervisor:      Area code:            Number:


   If for any reason you do not intend to nominate a Supervisor, please provide your reasons in the
                                              box below.




                        I request that a Summary instalment Order be made on the above terms.




Signature:


Date:        Day:               Month:                     Year:
                                                                                             Estate No:

                                            STATEMENT OF AFFAIRS
                                   (Pursuant to Insolvency Act 1967 / Insolvency Act 2006)
            For use in relation to Bankruptcy / No Asset Procedure / Summary Instalment Orders

      Please ensure that all questions have been answered as fully and accurately as possible. If necessary please use
      additional paper and firmly attach it to this form. Depending on your answers, you may be required to forward
      additional documents such as a copy of a pay slip or trust deed etc.

      To avoid confusion please write your answers clearly in blue or black ink. Please ensure that any additional
      pages or documentation have your surname or estate number (if known) written at the top of each additional page,
      in case they become separated from the main document.



                                            PART A - PERSONAL DETAILS
 Applicant Identification

1. First Name(s):                                                     Last Name:


1b. List any other personal names used in the last 10 years, or the name you are commonly known by:
    First Name(s):                                                    Last Name:




1c. Date of Birth:                                            1d. Gender:      Male       Female


1e. Preferred Title:    Mr   Mrs      Ms     Miss   Other Please specify:

 Contact Details
2. At what address do you currently live?




                                                                                                          Postcode:

2b. Do you own or are you buying this property?       Yes        No

2c. When did you move into this property?

2d. What is your correspondence address (if different to your residential address)?




                                                                                                          Postcode:

2e. Home Telephone:     0                                   2f. Work Telephone:    0


2g. Mobile Telephone:   0


2h. Email Address:

2i. What is your preferred method of contact?         Email             Post to Correspondence Address

                                                                                                                      Page 1 of 30
                                              PART A - PERSONAL DETAILS
3. Have you lived at any other addresses in the past 2 years?            Yes    No

Please provide details of the addresses you have lived at in the past 2 years.




3b. Do/did you own or are/were you buying this property(s)?            Yes     No


Accommodation Details

4. Please describe what type of accommodation payments you are making
  Rent            Board              Mortgage Payments
  Other (please specify)
  None (please explain)
4b. How much per week do you pay?         $

4c. To whom do you make these payments?

Please provide name & address details below.
Name                                   Address                                                     Phone Number




                                                                                Postcode:

4e. What is your relationship to this person / organisation / trust?



Passport

5. Do you have any current passport(s)?          Yes      No

Please provide details of your current passport(s).

Name as shown in passport              Country of Issue        Date of Issue         Expiry Date   Passport Number




Firearms

6. Do you hold a firearms licence?       Yes      No



                                                                                                                     Page 2 of 30
                                          PART A - PERSONAL DETAILS
Ethnicity
7. Tick as many boxes as you need to show which ethnic group(s) you belong to.


  NZ Maori         NZ European or Pakeha            Other European (please specify)

  Chinese          Indian                           Pacific Island (please specify)

  Australian       South African                    Other (please specify)



Emergency Contact
8. Enter a name, address and phone number of a relative or contact person who does not live with you.
  Name                              Address                                                       Phone Number




                                                                              Postcode:

What is their relationship to you?


Employment

9. What is your IRD number?                    /             /
9b. Which period did your last tax return cover (if any) ?

9c. Are you due any tax refunds?              Yes       No



10.What is your usual trade or profession?



11. Select the option that best describes your current employment status.

  Domestic         Currently employed         Student            Unemployed – no benefit     Unemployed – with benefits
  Trading – on own account                    Trading – as a Limited Liability Company       Trading – in Partnership

  Retired          Sickness benefit/ACC       Other (please specify)

12. Enter the name and address of your current employer.
  Name                               Address                                                        Phone Number




                                                                                 Postcode:

13. How long have you been unemployed? Years:                          Months:

13b. Are you likely to gain paid employment in the next 12 months?         Yes      No

14. Enter the name and address of your last employer.
  Name                                  Address                                                     Phone Number




                                                                                 Postcode:
                                                                                                                        Page 3 of 30
                                              PART A - PERSONAL DETAILS
 Income
15. Please provide details of the income you receive. If you receive more than one type of income, list each one.

Type of Income:                                                    Average Net Weekly Income:        $
                                                                                                     $
                                                                                                     $

15b. From whom do you receive this income? Please provide details below (if different to your answer to Question 12).
    Name                                  Address                                                               Phone Number




    Please attach documentation confirming the amount of income you receive from this source (e.g. recent
    payslip or a letter from your employer).


Spouse/Partner
This information will only be used to calculate your ability to make repayments from your own income.

16. Do you have a spouse or partner?              Yes          No            (If No, move to Question 17)

16b. Does your spouse/partner live with you?            Yes             No


16c. What is your spouse/partner’s occupation?

16d. What is your spouse/partner’s net weekly income?               $


16e. Please provide the full name of your spouse/partner.




Dependents
17. Do you have any dependents residing with you, e.g. children, parents, invalid relatives (not receiving a benefit)?
     Yes      No     (If No, move to Question 19)

  List any dependents residing with you. If you have more than one dependent, list each one.

      Full Name:                                                                     Relationship:                         Age:




18. Do you receive any payments for your dependents which you have not already mentioned?                           Yes        No

18b. If so, how much per week?            $



18c. Do you pay child support?                 Yes            No              18d. Amount outstanding?      $


18e. What is your monthly contribution?       $                               18f. Are your payments up to date?    Yes    No

                                                                                                                                Page 4 of 30
                                          PART A - PERSONAL DETAILS

19. Do you have any outstanding court fines?              Yes         No        19b. Amount outstanding?   $


19c. What is your monthly commitment to these?        $



20. Do you have any outstanding reparation orders?              Yes        No   20b. Amount outstanding?   $


20c. What is your monthly commitment to these?        $




21. Do you owe any money to WINZ (eg from an advance or overpayment of benefit)?                  Yes          No
21b. Amount outstanding?    $

21c. What is your monthly contribution?   $



22. Please complete the budgeting information below.

When you are completing this budget form, please include all income sources for the household, e.g. including your partner /
spouse if applicable, and list the total expenses for the household. Please note that income from other people will only be
taken into consideration when determining your own personal ability to make repayments.

Enter the number of adults this budget covers

Enter the number of children this budget covers

HOUSEHOLD INCOME                                      Weekly     Monthly

Wages/Salary                                      $
Income Support Payments                           $
Other Income                                      $                         Please specify:
Total Income                                      $

HOUSEHOLD COSTS                                       Weekly     Monthly

Rent or Board                                     $
Mortgage                                          $
Groceries                                         $
Power                                             $
Gas                                               $
Phone (landline/mobile/internet)                  $
Rental of Goods (e.g. TV)                         $
Rates                                             $
House Maintenance                                 $
Household Goods                                   $
House Insurance                                   $
Contents Insurance                                $
Total Household Costs                             $

TRAVEL COSTS                                          Weekly     Monthly

Fares (e.g. bus, train)                           $
Petrol / fuel                                     $
Car Insurance                                     $
Vehicle Registration                              $
Vehicle WOF                                       $
Vehicle Maintenance/Repairs                       $
Total Travel Costs                                $




                                                                                                                    Page 5 of 30
                                          PART A - PERSONAL DETAILS
FAMILY COSTS                                          Weekly   Monthly

Child Support Payments                            $
School Donations                                  $
School Fees                                       $
School Uniforms                                   $
Medical Costs                                     $
Dental Costs                                      $
Prescription Costs                                $
Pet Registration Fees                             $
Vet Fees                                          $
Clothes & Shoes                                   $
Holidays                                          $
Gifts                                             $
Life Insurance                                    $
Superannuation                                    $
Total Family Costs                                $

GENERAL COSTS                                         Weekly   Monthly

Alcohol                                           $
Cigarettes                                        $
Entertainment                                     $
Child Care                                        $
Hire Purchases / Secured Debts                    $
Bank Fees                                         $
Club Fees                                         $
Subscription Fees                                 $
Donations                                         $
Fines                                             $
Reparations                                       $
Other (please specify)                            $
Total General Costs                               $


Please calculate the total income, costs and surplus or shortfall.

                                                      Weekly   Monthly

Total Household Income (A)                        $

   Total Household Costs                   $
   Total Travel Costs                      $
   Total Family Costs                      $
   Total General Costs                     $

Total of All Costs (B)                            $


Total Household Surplus/Shortfall                 $
(Total A – Total B)




                                                                         Page 6 of 30
                                 PART B – BACKGROUND TO INSOLVENCY

For the purposes of these questions, the term “Property” means land, money, goods, things in action, goodwill, and every
valuable thing, whether real or personal, and whether situated in New Zealand or elsewhere, and includes obligations,
easements and every description of estate, interest, and profit, present or future, vested or contingent, arising out of or
incident to property.

23. Have you ever been adjudged bankrupt before?               Yes      No

23b. When and where?

23c. What was your Insolvency Number?



24. Have you ever been accepted into a No Asset Procedure (NAP) before?                  Yes        No

24b. When and where?

24c. What was your Insolvency Number?



25. Have you ever entered a Summary Instalment Order (SIO) before?                  Yes        No

25b. When and where?

25c. What was your SIO Number?

25d. Please provide the name and phone number of the SIO Supervisor.

Name:                                                                   Phone:      0


25e. Is the SIO still current?     Yes        No            25f. Does the Supervisor still hold any funds?         Yes         No


26. When did you become unable to pay your debts as they became due? What made you choose this date?




27. Have you taken any steps since then to deal with your debts? Please provide details.

  Joined a creditors’ pool       Sought budget advice          Tried to settle your debts            Visited the ITS website


  Other (please specify)


28. Do you have a solicitor at present?            Yes    No

28b. Have you had a solicitor act on your behalf in the past 2 years?        Yes   No

28c. Please provide name & contact details for your solicitor and the name of the firm (if any).
  Name                                    Address                                                         Phone Number




                                                                             Postcode:
                                                                                                                           Page 7 of 30
                                PART B – BACKGROUND TO INSOLVENCY
29. Do you have an accountant at present?          Yes      No

29b. Have you had an accountant act on your behalf in the past 2 years?       Yes       No

29c. Please provide name and contact details for your accountant and the name of the firm (if any).
  Name                                 Address                                                        Phone Number




                                                                            Postcode:



30. Have any of your possessions or property been seized in the past 6 months e.g. by a court bailiff or landlord?    Yes         No
Give details of
what was
seized, when
and by whom:

31. Have you given away any of your possessions or property (including money) in the past 2 years?        Yes        No
Give details of
what you gave
away, when, and
to whom:



32. Has any person or organisation left any possessions or property (including money) in your care?      Yes     No

Give details of
what was left,
when, and by
whom:



33. Does any person or organisation have any of your property (including money)?        Yes     No

Give details of
what the property
is, and who has
it:


34. Have you paid any outstanding debts in the past month, excluding household expenses such as rent, power and excluding
any fines?          Yes     No

Give details of
who you paid
and how much:



35. Have you raised finance (e.g. mortgage / loan) using any of your possessions or property in the past 12 months?         Yes     No
Give details -
what money was
raised, who
loaned it, over
what property:


36. Have you lost more than NZ$5,000 betting or gambling in the past 12 months?         Yes      No

Give details and
estimate how
much:

                                                                                                                          Page 8 of 30
                                   PART B – BACKGROUND TO INSOLVENCY

37. Are you currently involved in any court case?      Yes      No     (If No, move to Question 38)

37b. Nature of the Case:
(If it relates to a debt owed by
you, how much do you owe?)


37c. Court Name:

37d. Name of Other Party:

37e. Solicitor Representing You:

37e. Solicitor Representing Other Party:                                                                           No

37f. Date of next hearing:



38. Have you signed any formal property sharing agreement with your spouse/partner in the past 5 years?   Yes      No
   (eg a matrimonial property agreement or pre-nuptial agreement)

Give details:




Who holds a copy of the agreement?

      Please attach a copy if you have one.




                                                                                                                Page 9 of 30
             PART C – FINANCIAL CIRCUMSTANCES (ASSETS AND LIABILITIES)
Please only list assets/liabilities that are personal to you or jointly held. Do not include business,
partnership or company assets. These will be listed in a separate section of the Statement of
Affairs.
39. Do you have any bank accounts, including building society accounts, overseas funds, credit union, TAB, etc?           Yes     No

Please provide details of each of the accounts you have.

Name of Account               Joint?      Bank and Branch        Account Number            Account Type                   Balance
                                                                                                                      $
                                                                                                                      $
                                                                                                                      $
                                                                                                                      $


If any of the above accounts are
held jointly, please state who the
co-owner is:


40. Do you own any shares, either in New Zealand or overseas? Include Government inflation bonds, bonus bonds, unit trust
investments, public company shares, etc.   Yes      No

Please provide details of all the shares you own.

 Name of Company                     How Many Shares? Location of Share Certificate or FIN Number         Approximate Value
                                                                                                          $
                                                                                                          $
                                                                                                          $
                                                                                                          $


41. Do you own any Life Insurance policies?         Yes     No

Please provide details of each of the Life Insurance policies you own.

Name of Life Insured             Policy Number            Name of Insurance Company   Date Paid Up To         Surrender Value
                                                                                                              $
                                                                                                              $
                                                                                                              $
                                                                                                              $




42. Do you have any superannuation funds (including Kiwisaver), either in New Zealand or overseas?                Yes       No

Please provide details of each of the superannuation or Kiwisaver schemes that you have.
                                                                                       Date Commenced
 Name of Fund               Address of Fund Holder / Fund Manager Policy Number        Contribution   Surrender Value
                                                                                                                  $
                                                                                                                  $
                                                                                                                  $
                                                                                                                  $




                                                                                                                          Page 10 of 30
             PART C – FINANCIAL CIRCUMSTANCES (ASSETS AND LIABILITIES)

43. Are you currently involved with any Trust?        Yes        No    (If No, move to Question 45)
Name of Trust(s)




Please provide the following details for each of the Trusts you are involved with. (If more than one, please use a separate page).

43b. What is the nature of your involvement in the Trust? (Select all that apply.)           Trustee         Settlor           Beneficiary

43c. Please provide each of the Trustees’ names with address and phone number.
  Name                                  Address                                                               Phone Number


                                                                                    Postcode:



                                                                                    Postcode:

43d. Please list the assets of the Trust, and current value.
  Asset                                     Current Value                   Asset                                          Current Value
                                            $                                                                          $
                                            $                                                                          $

43e. Have you ever transferred any personal assets or money to the Trust?              Yes        No
43f. Please list the assets or money transferred to the Trust.
                                                                                                                       Estimated Value at
  Asset/Money Transferred                                                                 Date Transferred             Time of Transfer
                                                                                                                       $
                                                                                                                       $
                                                                                                                       $
                                                                                                                       $

43g. Have you been paid any money from this Trust in the past 2 years?              Yes      No
43h. Does the Trust owe you any money?          Yes    No
43i. Do you owe the Trust any money?            Yes    No
43j. Do you hold a copy of the Trust Deed(s) for this Trust?          Yes      No

      Please attach a copy of the Trust Deed(s).

If you do not hold a copy, please state the name, address and phone number of the individual or organisation that does
have a copy of the Trust Deed(s) for this Trust.
   Name                                 Address                                                Phone Number




                                                                                    Postcode:


44. Have you been a beneficiary of any Trust not listed above in the past 2 years?                Yes    No
Please state when and the value of the benefit you received.




45. Have you transferred any personal assets or money to any other Trust in the past 5 years?                    Yes         No
 Please state when, and state the value and a description of the assets/money you transferred.




                                                                                                                                  Page 11 of 30
             PART C – FINANCIAL CIRCUMSTANCES (ASSETS AND LIABILITIES)

46. Have you loaned any money to any person or organisation that has not been repaid?      Yes     No (If No, move to Qu 47)
Please provide details of the loan. If you have loaned money to more than one person / organisation, please list the
additional details on a separate page.

Name, address and phone number of the person / organisation:
  Name                                 Address                                                       Phone Number




                                                                             Postcode:

46b. Relationship of person / organisation to You:

46c. Nature of Debt:

46d. Amount Owing:          $


46e. When is the loan due to be repaid?

46f. Is there a written contract, and who has a copy?

46g. Do you hold any security over this loan (e.g. mortgage?)       Yes     No

46h. Description of the Secured Property



46i. Estimated Value of the Secured Property:    $




47. Do you have an interest in any deceased estate?       Yes      No      (If No, move to Question 48)
   ie have you been left money or assets by anyone who has died, that you have received in the past 2 years
   or which is still owed to you.
Please provide details of the deceased estate. If there is more than one, please list the details on a separate page.
47b. Name of Deceased:

47c. Relationship to You:

47d. Estimate the value of your interest in this deceased estate.    $


47e. Please provide the name, address and phone number of the person / organisation administering the deceased
estate.
  Name                               Address                                                    Phone Number




                                                                             Postcode:




48. Have you received any payments from a deceased estate in the past 2 years?            Yes      No
Please provide details.




                                                                                                                        Page 12 of 30
             PART C – FINANCIAL CIRCUMSTANCES (ASSETS AND LIABILITIES)

49. Please list your personal belongings and household effects below. List only household items over the value of $1,000
(use the combined value of items that are part of a set eg golf clubs, dining table and chairs). You must declare all non-
essential assets and any valuable personal belongings or collections, including jewellery, cameras, artworks, collectibles,
antiques and intellectual property. Do not include items on Hire Purchase. Note that you will be allowed to retain personal
belongings and effects and tools of trade, at the discretion of the Official Assignee.

                                                                                  Approximate
Description of Asset                       Location of Asset                      Age                  Resale Value    Jointly Owned
                                                                                                   $                      Yes    No
                                                                                                   $                      Yes    No
                                                                                                   $                      Yes    No
                                                                                                   $                      Yes    No
                                                                                                   $                      Yes    No
                                                                                                   $                      Yes    No

Please provide details of the co-owner of the asset(s):
  Name                                 Address                                                              Phone Number




                                                                                 Postcode:




Real Estate

50. Do you own or have an interest in any land or buildings (including Maori land)?          Yes       No (If No, move to Question 51)

Please provide details of all land or buildings that you own. If there is more than one, please list the details on a separate page.
50b. Address of Property:

50c. What type of property is it?
  Residential          Farm           Commercial             Other (please specify)
50d. Is the property jointly owned?          Yes        No

50e. Name of Co-Owner:

50f. Market Value:          $

50g. Is there a mortgage on this property?          Yes         No

50h. Amount Owed:       $

50i. Name of Mortgagee:

50j. Is the property insured?       Yes    No

50k. Name and Address of Insurer or Broker

50l. Insurance Policy Number:

50m. Is this property registered as a Joint Family Home?               Yes      No

50n. Is the property rented out?          Yes      No                50o. Monthly Rental:    $

50p. If rented out, where is the rent paid to (including bank and account number):
  Name                                    Address                                                       Bank Details




                                                                              Postcode:

                                                                                                                           Page 13 of 30
             PART C – FINANCIAL CIRCUMSTANCES (ASSETS AND LIABILITIES)

 Asset Disposal

51. In the past 2 years have you sold any assets including land and buildings? Do not include motor vehicles.
  Yes       No      (If No, move to Question 52)

Please provide details of each asset sold. If more than two, list the details on a separate page.

51b. Description of Asset:

51c. Net Amount Received:     $                               52d. Date Sold:

51e. Name of Buyer:

51f. What relationship does the buyer have to you?
  Relative/spouse         Friend     Business associate      None      Other (please specify)

51g. What did you do with the money you received from this sale?


51h. Provide the name and address of any agent, solicitor or broker involved in the sale.
  Name                                  Address                                                     Phone Number




                                                                           Postcode:



51b. Description of Asset:

51c. Net Amount Received:     $                               52d. Date Sold:

51e. Name of Buyer:

51f. What relationship does the buyer have to you?
  Relative/spouse         Friend     Business associate      None     Other (please specify)

51g. What did you do with the money you received from this sale?


51h. Provide the name and address of any agent, solicitor or broker involved in the sale.
  Name                                 Address                                                      Phone Number




                                                                           Postcode:




                                                                                                                   Page 14 of 30
              PART C – FINANCIAL CIRCUMSTANCES (ASSETS AND LIABILITIES)
Motor Vehicles/Transportation
52. Do you own 1 or more motor vehicles, for example a car, motorcycle, boat, truck, caravan or trailer?                Yes    No
52b. Do you use a borrowed motor vehicle?       Yes     No
Please provide details of each of the motor vehicle(s) you own or use below. If there are more than two, please list the
details on a separate page. (If you have answered No to both questions, move to Question 53)
52c. Type of Vehicle (e.g. car, boat):

52d. Registration Number:                                               52e. Make:

52f. Model:                                                             52g. Year:

52h. Name of Vessel (if a boat):

52i. Present Location:

52j. Name of Registered Owner:

52k. Name of Insurance Company:

52l. Amount Insured For:             $                                  52m. Insurance Expiry Date:

52n. Does this vehicle have a current WOF/COF?       Yes         No     52o. Does it have a current registration?             Yes    No

52p. Condition of the Vehicle:

52q. Current Odometer Reading:                                          52r. Estimated Resale Value:        $

52s. Have you borrowed money against this vehicle?         Yes         No

52t. Please provide the name and address of the Loan or Hire Purchase company


52u. Total Amount Owed on HP or to Secured Creditor (if any):               $



52c. Type of Vehicle (e.g. car, boat):

52d. Registration Number:                                                   52e. Make:

52f. Model:                                                                 52g. Year:

52h. Name of Vessel (if a boat):

52i. Present Location:

52j. Name of Registered Owner:

52k. Name of Insurance Company:

52l. Amount Insured For:                 $                                  52m. Insurance Expiry Date:

52n. Does this vehicle have a current WOF/COF?        Yes         No        52o. Does it have a current registration?         Yes    No

52p. Condition of the Vehicle:

52q. Current Odometer Reading:                                              52r. Estimated Resale Value:     $

52s. Have you borrowed money against this vehicle?          Yes        No

52t. Please provide the name and address of the Loan or Hire Purchase company


52u. Total Amount Owed on HP or to Secured Creditor (if any):               $

                                                                                                                              Page 15 of 30
              PART C – FINANCIAL CIRCUMSTANCES (ASSETS AND LIABILITIES)

Motor Vehicles/Transportation

53. Have you sold any motor vehicles over the past 2 years? Do not include business vehicles.
    Yes       No      (If No, move to Question 54)


Please provide details of the motor vehicle(s) you have sold over the past 2 years below. If there are more than two,
please list them on a separate page.

53b. Type of Vehicle (e.g. car, boat):                                  53c. Name of Vessel:

53d. Registration Number:                                     53e. Make:

53f. Model:                                                   53g. Year:

53h. Sale Price:              $                         53i. Date Vehicle Sold:

53j. What did you do with the proceeds?

53k. What relationship does the buyer have to you?
  Relative/spouse       Friend      Business associate       None     Other (please specify)


53b. Type of Vehicle (e.g. car, boat):                                 53c. Name of Vessel:

53d. Registration Number:                                     53e. Make:

53f. Model:                                                   53g. Year:

53h. Sale Price:              $                        53i. Date Vehicle Sold:

53j. What did you do with the proceeds?

53k. What relationship does the buyer have to you?
  Relative/spouse       Friend     Business associate       None      Other (please specify)



Other Assets
54. Please record any other personal assets and their values not already declared on this form, including racehorses,
pedigree animals and livestock.

Description of Item                              Location                               Cost               Approximate Value
                                                                                        $                  $
                                                                                        $                  $
                                                                                        $                  $
                                                                                        $                  $
                                                                                        $                  $




                                                                                                                        Page 16 of 30
             PART C – FINANCIAL CIRCUMSTANCES (ASSETS AND LIABILITIES)
Personal Creditors (People and businesses you personally owe money to)
Secured Creditors and Hire Purchase Creditors (don’t include those holding security over a motor vehicle or
real estate)

This applies where creditors have the right to repossess any goods or property in your control if you do not pay them.
This right often arises in Hire Purchase agreements.

55. Do you have any secured creditors or Hire Purchase creditors?           Yes    No (If No, move to Question 56)
Please provide details of any secured creditors and Hire Purchase creditors you have that have not already been listed
in this Statement of Affairs. If there are more than two, please list them on a separate page.

Name and address of creditor:
  Name                                  Address                                                     Phone Number




                                                                          Postcode:

55b. Type of Security (eg HP):

55c. Description of Item:

55d. Estimated Present Value:     $               55e. Amount Owed:   $                 55f. Net Value:   $


55g. Is this a joint debt? If so, with whom?

55h. Account number or reference:



Name and address of creditor:
  Name                                  Address                                                     Phone Number




                                                                          Postcode:

55b. Type of Security (eg HP):

55c. Description of Item:

55d. Estimated Present Value:    $                55e. Amount Owed:   $                 55f. Net Value:   $


55g. Is this a joint debt? If so, with whom?

55h. Account number or reference:



Student Loan
56. Do you have a student loan?           Yes     No

56b. Student Loan Reference Number:                                       56c. Amount Owed:     $


56d. Name of Tertiary Qualification the Loan is/was funding:

56e. Last Year of Study:




                                                                                                                   Page 17 of 30
             PART C – FINANCIAL CIRCUMSTANCES (ASSETS AND LIABILITIES)

Credit Cards
57. Do you have any credit cards, charge cards or store cards?        Yes       No
Please provide details of credit cards, charge cards and store cards. If the debt is jointly owed please specify with
whom.
Name of Bank, Store or Card,
e.g. BNZ, Farmers, ASB Visa                           Joint Debt?             Reference Number                Amount Owed
                                                                                                          $

                                                                                                          $

                                                                                                          $

                                                                                                          $

                                                                                                          $




58. Do you personally owe money to anyone else?              Yes      No
Provide details of anyone else you personally owe money to here.
                                                                      Joint        Amount        Goods/Services
Creditor name:              Postal Address:                           Debt?        Owed:         Received:              Date incurred:
                                                                               $

                                                                               $

                                                                               $

                                                                               $

                                                                               $

                                                                               $

                                                                               $

                                                                               $

                                                                               $

                                                                               $

                                                                               $

                                                                               $

                                                                               $

                                                                               $

                                                                               $

                                                                               $

                                                                               $

                                                                               $




                                                                                                                         Page 18 of 30
                 PART D – CAUSE OF INSOLVENCY AND BUSINESS DETAILS
59. Are you currenty, or have you been in the past 2 years, a director of a Limited Liability Company or an officer of an
Incorporated Society registered with the Companies Office in New Zealand, or overseas? Do not include businesses you
have run as a sole trader or in partnership.
     Yes
     No

60. Have you ever been in business, either as a sole trader or as a member of a partnership? Do not include details of Limited
Liability Companies or Incorporated Societies.

     Yes
     No

If you answered No to both of the above questions, please answer questions 61, 62 and 63 below then turn to the
back page and sign and date the document.
If you answered yes to either of the above questions, please go straight to question 64 and continue from there.

Cause of Insolvency (Never been in Business)

61. What do you believe is the MAIN cause of your insolvency?
  Unemployment or loss of income         Adverse legal action      Liabilities due to guarantees

  Gambling, speculation and extravagance in living                 Ill health or absence of health insurance

  Domestic discord or relationship breakdowns                      Excessive use of credit facilities

  Excessive interest payments                                      Seasonal conditions including floods and drought

  Other (please specify)


62. Are there any other causes of your insolvency? Select all that apply.

  Unemployment or loss of income         Adverse legal action      Liabilities due to guarantees

  Gambling, speculation and extravagance in living                 Ill health or absence of health insurance

  Domestic discord or relationship breakdowns                      Excessive use of credit facilities

  Excessive interest payments                                      Seasonal conditions including floods and drought

  Other (please specify)



63. Do you have any further comments as to the cause(s) of your insolvency?
  Yes       No




                                                                                                                   Page 19 of 30
                  PART D – CAUSE OF INSOLVENCY AND BUSINESS DETAILS
If you haven’t been in business and answered No to questions 59 and 60, go straight to the back page.

Cause of Insolvency (Have been in Business)
64. What do you believe is the MAIN cause of your insolvency?

  Unemployment or loss of income
  Adverse legal action
  Liabilities due to guarantees
  Gambling, speculation and extravagance in living
  Ill health or absence of health insurance
  Domestic discord or relationship breakdowns
  Excessive use of credit facilities
  Economic conditions including external influences, competition and increases in costs
  Lack of business ability including under-quoting or failure to assess potential of business
  Excessive interest payments
  Excessive drawings
  Inability to collect debts due to disputes, faulty work or bad debts
  Failure to keep proper books of account and costing records
  Lack of sufficient working capital
  Failure to provide for taxation
  Seasonal conditions including floods and drought
  Other (please specify)


65. Are there any other causes of your insolvency? Select all that apply.

  Unemployment or loss of income
  Adverse legal action
  Liabilities due to guarantees
  Gambling, speculation and extravagance in living
  Ill health or absence of health insurance
  Domestic discord or relationship breakdowns
  Excessive use of credit facilities
  Economic conditions including external influences, competition and increases in costs
  Lack of business ability including under-quoting or failure to assess potential of business
  Excessive interest payments
  Excessive drawings
  Inability to collect debts due to disputes, faulty work or bad debts
  Failure to keep proper books of account and costing records
  Lack of sufficient working capital
  Failure to provide for taxation
  Seasonal conditions including floods and drought
  Other (please specify)



66. Do you have any further comments as to the cause(s) of your insolvency?
  Yes      No




                                                                                                        Page 20 of 30
                    PART D – CAUSE OF INSOLVENCY AND BUSINESS DETAILS
67. Are you currently, or have you been in the past 2 years, a director of a Limited Liability Company or an officer of an
Incorporated Society registered with the Companies Office in New Zealand, or overseas? (Do not include businesses you
have run as a sole trader or in partnership). If no, please go to Question 68.

If you have never been in business, please go straight to the back page.

Please provide details of the Limited Liability Companies and/or Incorporated Societies you have been a director or an
officer of in the past 2 years. If there are more than two, please list the details on a separate page.
Company/Society Name:

Address:




67b. Position Held:

67c. Shares Held:

67d. Who ran the company?

67e. How much does the company/society owe you?         $

67f. How much do you owe the company/society?           $

67g. Is the company/society the trustee of a Trust?         Yes     No

67h. Do you hold a copy of the latest financial statement for this company/society?      Yes     No

      If you have a copy of the financial statement please attach it to this application.

If not, please state the name and address of the individual or organisation that does have a copy of the financial
statement for this company/society.




Company/Society Name:

Address:




67b. Position Held:

67c. Shares Held:

67d. Who ran the company?

67e. How much does the company/society owe you?         $

67f. How much do you owe the company/society?           $

67g. Is the company/society the trustee of a Trust?         Yes     No

67h. Do you hold a copy of the latest financial statement for this company/society?      Yes     No

      If you have a copy of the financial statement please attach it to this application.

If not, please state the name and address of the individual or organisation that does have a copy of the financial
statement for this company/society.



                                                                                                                     Page 21 of 30
                  PART D – CAUSE OF INSOLVENCY AND BUSINESS DETAILS

68. Have you have ever been in business, either as a sole trader or as a member of a partnership? (Do not include details
of Limited Liability Companies or Incorporated Societies).

If you have never been in business, please go straight to the back page.


Please provide the name of your business/partnership.

Business Name:

Trading Name (if any):



69. Was the business run in partnership with anyone else?
   Yes       No

Please provide the name, address and phone number of the partner(s) and comment if the partner is also bankrupt.

  Name                                 Address                                                      Phone Number




                                                                          Postcode:




                                                                          Postcode:




69b. Do you have a copy of the partnership agreement?           Yes     No

69c. Do you have a copy of the latest financial accounts?       Yes     No
      If so, please attach them to this application.

If you do not have a copy, please provide the name and address of an individual or organisation that has.
  Name                                 Address                                                      Phone Number




                                                                          Postcode:




                                                                                                                   Page 22 of 30
                  PART D – CAUSE OF INSOLVENCY AND BUSINESS DETAILS

70. What was the nature of your business?




71. Did your business employ any staff?            Yes         No

71b. How many staff did your business employ?



72. When did your business start and cease trading?

Started:                                     Ceased:



73. Did you have a landlord or agent for your business premises?
   Yes     No

Was your landlord or agent a person or an organisation?          A person           An organisation

73b. Please provide the name, address and phone number of the landlord or agent of your business premises.

  Name                                 Address                                                        Phone Number




                                                                               Postcode:

73c. What relationship does the agent/landlord have to you?
  Relative/spouse        Friend       Business associate       None         Other Please specify:

73d. What is/was the rental amount?     $                           Per week        Per month

73e. What date is/was the rent paid up to?

73f. Is/was there a lease/tenancy agreement?             Yes     No

73g. Do you have a copy of the lease/tenancy agreement?               Yes      No
      If so, you must attach it to this application.
If you do not hold a copy, please provide the name, address and phone number of an individual or organisation that has.
  Name                                 Address                                                        Phone Number




                                                                               Postcode:




                                                                                                                     Page 23 of 30
                  PART D – CAUSE OF INSOLVENCY AND BUSINESS DETAILS

74. Are there any contracts requiring completion?
  Yes       No

Please provide details of the contracts that require completion.




74b. Do you have a copy of the contract(s)?         Yes      No

     If so you must send it to ITS by post, email or fax, or attach it now.

If not, please provide the name, address and phone number of an individual or organisation that has.
   Name                                Address                                                     Phone Number




                                                                          Postcode:


75. Please provide the physical address of your business/partnership.




                                                                          Postcode:


75b. Telephone:       0                                       74c. Fax:   0


75d. Please provide the correspondence address of your business/partnership (if different to above).




                                                                              Postcode:


75e. Please provide the website and email address of your business/partnership (if any).

Website:

Email Address:




                                                                                                                  Page 24 of 30
                  PART D – CAUSE OF INSOLVENCY AND BUSINESS DETAILS
76. Was the business registered for GST?              Yes   No
Please provide details of the GST registration.
76b. Registered Name:

76c. GST Number:                    /             /
76d. GST Registration Type:                 Invoice Basis        Payments Basis       Hybrid

76e. Date of Last Return:



77. Who was responsible for completing the daily accounting records?         Myself      Someone else
If it was not you, please list their name, address and phone number below.
  Name                                  Address                                                     Phone Number




                                                                          Postcode:


77b. Did this person/organisation also complete the annual accounts?
If not, please list the name, address and phone number of the person/organisation that did below.
  Name                                  Address                                                     Phone Number




                                                                          Postcode:




                                                                                                                   Page 25 of 30
                   PART D – CAUSE OF INSOLVENCY AND BUSINESS DETAILS

78. Do you hold the business records for your business or partnership?                   Yes       No

If so you must send them to ITS by post, email or fax.

If you do not hold a copy, please provide the name, address and phone number of an individual or organisation that has.

  Name                                 Address                                                          Phone Number




                                                                            Postcode:


79. Has your business paid any creditors in the past 6 months?           Yes     No

79b. Provide a list of the creditors your business has paid in the past 6 months, including the amounts paid.

 Name                               Address                                                      Date           Amount
                                                                                                                $
                                                                                                                $
                                                                                                                $
                                                                                                                $
                                                                                                                $



80. Has your business sold any assets in the past 6 months, other than motor vehicles?            Yes     No
Provide details of the assets your business or partnership has sold in the past 6 months, other than motor
vehicles.

80b. Asset Description:

80c. Sale Price:             $


80d. Name of Buyer:

80e. What relationship does the buyer have to you?
  Relative/spouse       Friend     Business associate       None        Other (please specify)

80f. If the business is no longer trading, what happened to the business assets?




80g. What happened to the proceeds from the sale of any assets, including motor vehicles?




Business Assets
81. Does your business have any bank accounts?           Yes       No
List any business bank accounts.
 Name of Account                    Bank and Branch                 Account Number               Account Type   Balance
                                                                                                                $
                                                                                                                $
                                                                                                                $
                                                                                                                $

                                                                                                                       Page 26 of 30
                   PART D – CAUSE OF INSOLVENCY AND BUSINESS DETAILS
82. Do you have any plant and equipment belonging to your business? Include implements, fixtures and fittings but exclude
motor vehicles, which will be described later.   Yes     No
List any plant and equipment belonging to your business.
                                 Identifying Numbers   Security Type            Security
Description of Item              or Characters         (if any)                 Holder (if any)         Resale Value   Amount Owed
                                                                                                        $              $

                                                                                                        $              $

                                                                                                        $              $



83. Do you have any stock belonging to your business? Include livestock and crops.                Yes       No
List any stock belonging to your business.
                                 Registration          Security Type            Security
Description of Item              Numbers               (if any)                 Holder (if any)         Resale Value   Amount Owed
                                                                                                        $              $

                                                                                                        $              $

                                                                                                        $              $


Motor Vehicles/Transportation
84. Does your business own 1 or more motor vehicles, for example a car, motorcycle, boat, truck, caravan or trailer?
  Yes         No

Please provide details of the motor vehicle(s) owned by your business below.

84b. Type of Vehicle (e.g. car, boat):

84c. Registration Number:                                          84d. Make:

84e. Model:                                                        84f. Year:

84g. Name of Vessel:

84h. Present Location:

84i. Name of Registered Owner:

84j. Name of Insurance Company:

84k. Amount Insured For:             $                             84l. Insurance Expiry Date:

84m. Does this vehicle have a current WOF/COF?             Yes         No

84n. Condition of the Vehicle:

84o. Current Odometer Reading:

84p. Estimated Resale Value:         $

84q. Have you raised money against this vehicle?         Yes      No

84r. Please provide the name and address of the Loan or Hire purchase company


84s. Total Amount Owed on HP or to Secured Creditor (if any):               $

84t. Does the vehicle have a current registration?       Yes      No

                                                                                                                           Page 27 of 30
                    PART D – CAUSE OF INSOLVENCY AND BUSINESS DETAILS

Motor Vehicles/Transportation

85. Has your business sold any motor vehicles (e.g. cars, boats, caravans, trailers, aircraft) over the past 2 years?
  Yes         No
Please provide details of the motor vehicle(s) your business has sold over the past 2 years below.

85b. Type of Vehicle:

85c. Registration Number:                                            85d. Make:

85e. Name of Vessel:

85f. Model:                                                         85g. Year:

85h. Sale Price:                     $                              85i. Date Vehicle Sold:

85j. What did you do with the proceeds?
85k. What relationship does the buyer have to you?

  Relative/spouse        Friend      Business associate      None      Other (please specify)



Business Debtors
86. Do any people or organisations owe your business money?           Yes         No
        If you have a list of your business’ debtors (people or organisations that owe your business money) you can attach
        it to this application. Otherwise you will need to provide details of each debtor below, and supply evidence of each
        debt.
Debtor name:                   Postal Address:                                Nature of debt:                     Amount owed:
                                                                                                                 $
                                                                                                                 $
                                                                                                                 $
                                                                                                                 $
                                                                                                                 $
                                                                                                                 $
                                                                                                                 $
                                                                                                                 $




                                                                                                                        Page 28 of 30
                 PART D – CAUSE OF INSOLVENCY AND BUSINESS DETAILS
Business Creditors
Preferential Creditors
87. Does your business have any preferential creditors?           Yes            No
    Preferential Creditors include Inland Revenue for GST or PAYE, and also wages, redundancy, holiday pay owing to
    employees, and customs levies. If you have a list of your business’ preferential creditors you can attach it to
    this application. Otherwise you will need to provide details of each preferential creditor here.
                                                                                             Goods/Services
 Creditor name:            Postal Address:                            Amount owed:           Received:      Date Incurred:
                                                                             $
                                                                             $
                                                                             $
                                                                             $


Secured Creditors
88. Does your business have any secured creditors?            Yes                No
     A secured creditor is one that has the right to repossess any goods or property owned by your business if your
     business does not pay them. They include mortgages, Hire Purchases, Chattel Securities and Retention of Title
     clauses. Do not include debts you have already described elsewhere in this document. If you have a list of your
     business’ secured creditors you can attach it to this application. Otherwise you will need to provide details of
     each secured creditor here.
                                                                                         Goods/Services
Creditor name:           Postal Address:                                 Amount owed:    Received:             Date Incurred:
                                                                             $
                                                                             $
                                                                             $
                                                                             $

Unsecured Creditors

89. Does the business owe money to anyone else?             Yes         No
    If you have a list of your business’ unsecured creditors you can attach it to this application. Otherwise you will
    need to provide details of each unsecured creditor.
                                                                                    Goods/Services
 Creditor name:             Postal Address:                      Amount owed:       Received:            Date incurred:
                                                                             $
                                                                             $
                                                                             $
                                                                             $


                                                     DOCUMENTS

       Please check back through this Statement of Affairs and ensure that you have attached all of
                                    the documents mentioned.

   Is there any additional information that you would like to provide to the Official Assignee, or comments you would like to
   make? If so please enter them below.




                                                                                                                     Page 29 of 30
Any personal information collected is for the purpose of administering the Bankruptcy, NAP or SIO in accordance with the
Insolvency Act 2006. The information will be used and retained by the Official Assignee and will be released to other parties
only with your authorisation or in compliance with the Privacy Act 1993 or the Insolvency Act 2006. You are obliged to provide
this information under the Insolvency Act 2006 and it is an offence to make a false statement under section 440 of the
Insolvency Act 2006. You may have access to and request correction of any of your personal information.




I hereby declare that the information I have provided in this Statement of Affairs, including any supporting documents,
provides a true and full representation of my financial affairs.




Full Name:

Signature:

Date:




 If you are already bankrupt, please forward this Statement of Affairs to ITS, Private Bag 4714, Christchurch. The date of your
 discharge from bankruptcy is calculated from the date on which the completed Statement of Affairs is accepted by ITS, and
 not from the date you were adjudicated bankrupt. Therefore the sooner you send your Statement of Affairs, the earlier you
 may be eligible for discharge from bankruptcy.

 If you wish to apply for Bankruptcy, No Asset Procedure or a Summary Instalment Order then you will also need to
 complete the appropriate application form and send it to the above address with this Statement of Affairs.



                                               Checklist for Statement of Affairs


   1.    Have you attached to this document an application form for bankruptcy, NAP or SIO?
         (You can find the application form in the forms section of the website under customer support).


   2.    Have you answered every question?



   3.    Is it written in blue or black ink?



   4.    Is proof of income attached?



   5.    Is it written clearly?



   6.    Is it signed and dated?


  NOTE: IF THE STATEMENT OF AFFAIRS IS NOT COMPLETE THEN IT MAY CAUSE A DELAY IN
              YOUR APPLICATION OR YOUR APPLICATION MAY BE REJECTED.



Version: November 2009
                                                                                                                   Page 30 of 30

								
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