Legal entity name*
Trading name
ABN*
Industry or business type
Business address
Contact name*
Contact name*
Position
Phone*
Phone*
Email*
Who owes the money
Full legal name or entity name*
Trading name
ABN or ACN
Date of birth
Last known address*
Previous address, if known
Phone
Email
Guarantor name and address, if any
Your account reference*
Date the debt arose*
Date payment fell due*
Date of last payment received
Original amount (A$)*
Payments received (A$)
Credits or adjustments (A$)
Interest claimed (A$)
Recovery costs claimed (A$)
Current balance claimed (A$)*
Balance calculated as at*
What allows you to claim interest or recovery costs?
If other, describe
Status of the account
Answer each one — if you don't know, choose Unknown rather than guessing.
Details of anything you answered yes to
What you're authorising us to do
Lowest settlement you'd accept (A$)
Longest payment term you'll allow
Special instructions or contact restrictions
Documents you're sending
Tick everything you're attaching.
Anything else you're attaching
Attach files
Your Declaration
the debt is genuinely owed and, so far as you know, legally enforceable
the balance is accurate at the date of referral, apart from anything disclosed above
the documents you've supplied are true copies of your records
you're entitled to collect this debt and authorised to instruct us
you've disclosed every dispute, payment, hardship request and court proceeding you know of
you'll tell us promptly if the debtor pays you directly, disputes the debt, or anything else material changes
you're authorised to give us the personal information in this form for the purpose of collecting the debt
Your full name*
Your position*
Submit
