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ACKNOWLEDGEMENT OF DEBT (Please complete form in FULL)
Interview Progress:
0
% / Page
1
of 4
DEBTOR'S DETAILS
How many Debtors are signing the Acknowledgment of Debt?
-- Click to Select --
1
2
3
Debtor 1 Details:
Is the Debtor a natural person or juristic person (e.g. trust, cc, company)?
Natural
Juristic
Full Name:
Is the Debtor a South African citizen?
Yes
No
ID Number:
Date of Birth:
Please provide the full name of the entity:
Registration No:
Please provide the full name of the entity's duly authorised representative:
Is the Representative a South African citizen?
Yes
No
ID Number:
Date of Birth:
It is advisable to obtain personal surety in the event that the debtor is a juristic person.
Would you like to include a suretyship clause in order to bind the signatory as surety and co-principal debtor?
No
Yes
Please complete the following information for the Debtor:
Telephone (W):
Telephone (H):
Telephone (Cell):
Email
Physical Address:
Address 1:
Address 2:
Suburb:
City:
Postal Code:
Province:
-- Click to Select --
Eastern Cape
Free State
Gauteng
Kwazulu-Natal
Limpopo
Mpumalanga
North West Province
Northern Cape
Western Cape
Check this box if the postal address is different
Postal Address:
Address 1:
Address 2:
Suburb:
City:
Postal Code:
Province:
-- Click to Select --
Eastern Cape
Free State
Gauteng
Kwazulu-Natal
Limpopo
Mpumalanga
North West Province
Northern Cape
Western Cape
Debtor 2 Details:
Is the Debtor a natural person or juristic person (e.g. trust, cc, company)?
Natural
Juristic
Full Name:
Is the Debtor a South African citizen?
Yes
No
ID Number:
Date of Birth:
Please provide the full name of the entity:
Registration No:
Please provide the full name of the entity's duly authorised representative:
Is the Representative a South African citizen?
Yes
No
ID Number:
Date of Birth:
It is advisable to obtain personal surety in the event that the debtor is a juristic person.
Would you like to include a suretyship clause in order to bind the signatory as surety and co-principal debtor?
No
Yes
Please complete the following information for the Debtor:
Telephone (W):
Telephone (H):
Telephone (Cell):
Email
Physical Address:
Address 1:
Address 2:
Suburb:
City:
Postal Code:
Province:
-- Click to Select --
Eastern Cape
Free State
Gauteng
Kwazulu-Natal
Limpopo
Mpumalanga
North West Province
Northern Cape
Western Cape
Check this box if the postal address is different
Postal Address:
Address 1:
Address 2:
Suburb:
City:
Postal Code:
Province:
-- Click to Select --
Eastern Cape
Free State
Gauteng
Kwazulu-Natal
Limpopo
Mpumalanga
North West Province
Northern Cape
Western Cape
Debtor 3 Details:
Is the Debtor a natural person or juristic person (e.g. trust, cc, company)?
Natural
Juristic
Full Name:
Is the Debtor a South African citizen?
Yes
No
ID Number:
Date of Birth:
Please provide the full name of the entity:
Registration No:
Please provide the full name of the entity's duly authorised representative:
Is the Representative a South African citizen?
Yes
No
ID Number:
Date of Birth:
It is advisable to obtain personal surety in the event that the debtor is a juristic person.
Would you like to include a suretyship clause in order to bind the signatory as surety and co-principal debtor?
No
Yes
Please complete the following information for the Debtor:
Telephone (W):
Telephone (H):
Telephone (Cell):
Email
Physical Address:
Address 1:
Address 2:
Suburb:
City:
Postal Code:
Province:
-- Click to Select --
Eastern Cape
Free State
Gauteng
Kwazulu-Natal
Limpopo
Mpumalanga
North West Province
Northern Cape
Western Cape
Check this box if the postal address is different
Postal Address:
Address 1:
Address 2:
Suburb:
City:
Postal Code:
Province:
-- Click to Select --
Eastern Cape
Free State
Gauteng
Kwazulu-Natal
Limpopo
Mpumalanga
North West Province
Northern Cape
Western Cape
CREDITOR'S DETAILS
How many Creditors are entitled to repayment in terms of the Acknowledgement of Debt?
-- Click to Select --
1
2
3
Creditor 1 Details:
Is the Creditor a natural person or juristic person (e.g. trust, cc, company)?
Natural
Juristic
Full Name:
Is the Creditor a South African citizen?
Yes
No
ID Number:
Date of Birth:
Please provide the full name of the entity:
Registration No:
Please provide the full name of the entity's duly authorised representative:
Is the Representative a South African citizen?
Yes
No
ID Number:
Date of Birth:
Please complete the following information for the Creditor:
Telephone (W):
Telephone (H):
Telephone (Cell):
Email
Physical Address:
Address 1:
Address 2:
Suburb:
City:
Postal Code:
Province:
-- Click to Select --
Eastern Cape
Free State
Gauteng
Kwazulu-Natal
Limpopo
Mpumalanga
North West Province
Northern Cape
Western Cape
Check this box if the postal address is different
Postal Address:
Address 1:
Address 2:
Suburb:
City:
Postal Code:
Province:
-- Click to Select --
Eastern Cape
Free State
Gauteng
Kwazulu-Natal
Limpopo
Mpumalanga
North West Province
Northern Cape
Western Cape
Creditor 2 Details:
Is the Creditor a natural person or juristic person (e.g. trust, cc, company)?
Natural
Juristic
Full Name:
Is the Creditor a South African citizen?
Yes
No
ID Number:
Date of Birth:
Please provide the full name of the entity:
Registration No:
Please provide the full name of the entity's duly authorised representative:
Is the Representative a South African citizen?
Yes
No
ID Number:
Date of Birth:
Please complete the following information for the Creditor:
Telephone (W):
Telephone (H):
Telephone (Cell):
Email
Physical Address:
Address 1:
Address 2:
Suburb:
City:
Postal Code:
Province:
-- Click to Select --
Eastern Cape
Free State
Gauteng
Kwazulu-Natal
Limpopo
Mpumalanga
North West Province
Northern Cape
Western Cape
Check this box if the postal address is different
Postal Address:
Address 1:
Address 2:
Suburb:
City:
Postal Code:
Province:
-- Click to Select --
Eastern Cape
Free State
Gauteng
Kwazulu-Natal
Limpopo
Mpumalanga
North West Province
Northern Cape
Western Cape
Creditor 3 Details:
Is the Creditor a natural person or juristic person (e.g. trust, cc, company)?
Natural
Juristic
Full Name:
Is the Creditor a South African citizen?
Yes
No
ID Number:
Date of Birth:
Please provide the full name of the entity:
Registration No:
Please provide the full name of the entity's duly authorised representative:
Is the Representative a South African citizen?
Yes
No
ID Number:
Date of Birth:
Please complete the following information for the Creditor:
Telephone (W):
Telephone (H):
Telephone (Cell):
Email
Physical Address:
Address 1:
Address 2:
Suburb:
City:
Postal Code:
Province:
-- Click to Select --
Eastern Cape
Free State
Gauteng
Kwazulu-Natal
Limpopo
Mpumalanga
North West Province
Northern Cape
Western Cape
Check this box if the postal address is different
Postal Address:
Address 1:
Address 2:
Suburb:
City:
Postal Code:
Province:
-- Click to Select --
Eastern Cape
Free State
Gauteng
Kwazulu-Natal
Limpopo
Mpumalanga
North West Province
Northern Cape
Western Cape
DETAILS REGARDING THE DEBT
Please provide the details of the Creditor's account, where payment is to be made:
How much is the amount of the debt owed in numerals?
eg 500,000.00
How did the debt arise?
Monies lent and advanced
Services rendered at Debtor's special instance and request
Goods sold and delivered at Debtor's special instance and request
Goods sold and delivered and/or services rendered at Debtor's special instance
A loan agreement concluded between the parties
A written agreement entered into between the parties
On what date did the debt arise?
Will interest accrue to the Capital Sum?
No
Yes
What annual rate of interest will be applicable?
The recommended rate of interest is 15,5%
What date will interest begin running on the debt?
What is the amount of the first installment payable?
When is the first installment payable?
What is the amount of the monthly installments payable?
When is the second installment payable?
On what day of every succeeding month with future installments be payable?
Please provide the details of the Creditor's account, where payment is to be made:
Account Name:
Bank:
Account Number:
Branch Code:
Reference:
