HAASBROEK-WILLEMSE INC - DEBT COUNSELLING
Welcome to the Haasbroek-Willemse Debt Counselling Instruction Page.

Please follow the following procedure when submitting a new instruction:

• Complete this form and e-mail supporting documents no later than day 30 of the 60 day debt suspension period;
• Payment should be made within 5 days of completing this form;
• You will then receive the draft affidavit within 10 days of date payment was received;
• The original commissioned affidavit should be returned to Haasbroek-Willemse within 5 days;
• You will receive a copy of the issued Notice of Motion within 10 days after having returned the original affidavit to us.

Legal fees can be deposited directly into the following account:

Haasbroek-Willemse Trust
Bank: ABSA
Account no: 1290410025
Ref: MD1002 / (Surname of Consumer)

Pleas forward proof of payment to martus@haaswil.co.za or fax it to (057) 212 9699

For more information, please contact Haasbroek-Willemse Incorporated at (057) 212 5665 or martus@haaswil.co.za

Debt Counsellor's Details
Name of Debt Counselling Company *
Your answer
Name of Debt Counsellor *
Your answer
Telephone number of Debt Counsellor *
Your answer
E-mail address of Debt Counsellor *
Your answer
Place of Business of Debt Counsellor *
(i.e. physical address)
Your answer
NCR Number *
Your answer
First Consumer's Details
First Consumer's Full Names and Surname *
Your answer
First Consumer's ID Number *
Your answer
First Consumer's Physical Address *
Your answer
Postal Address of First Consumer *
Your answer
Telephone number of First Consumer *
Your answer
Name of First Consumer's Employer *
(i.e. company name)
Your answer
Physical Address of First Consumer's Employer *
Your answer
Second Consumer's Details
(Only when applicable)
Second Consumer's Full Names and Surname
(Where Applicable)
Your answer
Second Consumer's ID Number
(Where Applicable)
Your answer
Name of Second Consumer's Employer
(Where Applicable)
Your answer
Other
Date of Registration on NCR Website *
Your answer
Date Form 17.1 was sent to creditors *
Your answer
Date Form 17.2 was sent to creditors *
Your answer
Proposed Monthly Installment as per Proposal *
Your answer
Date of first payment to creditors *
Your answer
Amount payable by Consumer *
Select number of Credit Accounts reflected on Proposal. Fees quoted are VAT inclusive
Documents to be e-mailed to martus@haaswil.co.za *
Tick documents available
Required
Date Legal Fees will be paid *
(Debt Counsellor must inform consumer of amount payable)
Your answer
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