Application form

Terms and conditions

Please reead carefully our Terms and conditions document befor you send your application form.


I hereby, confirm that I am duly authorized to sign this Power of Attorney, the contents of which I have noted and fully understood.

I nominate Shawn Davies NCRDC3115 to act as my lawful agent authorized to aquire information relating to my credit obligations and verify my credit score with the intention to:

1 ) Construct a credit profile of myself including my creditors, judgements, standing liabilities
and my overall credit ratings and scorings;
2 ) Engage with my creditors to obtain full and final settlement amounts;
3 ) To receive certified balances of what I owe to creditors;
4 ) To draw a report from any registered Credit Bureau;
5 ) To nominate an attoney to act on my behalf to rescind any judgement or order against me;
6 ) To allow Shawn Davies NCRDC3115 to sign the debt review application on my behalf.
7 ) Draw the requisite bank statements from my account, for at least three months prior to this authority;
8 ) Provide me with an outcome Report based on the findings.
9 ) To apply on my behalf for a Debt Review Order and/or any other form of debt
rehabilitation, including the transfer of my/our file from previous companies, should it be needed.
10 ) To substitute credit life or credit cover insurance, in particular on credit agreements where the credit provider requires such insurance, in terms of sec. 106(6) of the NCA, with a Credit Life Insurance Policy provided by Finsafe.
11 ) To undertake not to enter into any further Credit agreements
12 ) I will remain responsible for making all payments as re-arranged in full and on time. I am aware that making a short or late payment puts me at risk of termination or legal action by credit providers.
13 ) I confirm that I undestand and have had the the full debt review process explained to myself in a language that I understood.
14 ) After fulfillment of my obligations and all fees have been paid, the Debt Counsellor will issue a Clearance Certificate to all Credit Bureaus and Credit Providers.

Shawn Davies NCRDC3115 shall lawfully execute the terms of this Power of Attorney which can only
be terminated by me in writing and sent to the debt counsellor in writing.

I acknowledge that D&R Inc will be conducting extensive and consuming work on
my personal profile and should I for whatever reason terminate this mandate prematurely
then I acknowledge that I will be liable for any attoneys costs incurred.


1. Administration fee/rejection fee

A administration fee/rejection fee of R300.00 (excluding VAT) in respect of consumers whose applications have been accepted at the offices and continued to the 17.1 stage, regardless of whether the application continues or is rejected in terms of section 86(7)(a);

2. Restructuring Fees

2.1. A restructuring fee of the lesser of the first instalment of the debt re-arrangement plan in respect of a consumer whose applications have been accepted in terms of 86(7) (b) or 86(7) (c),with a maximum allowable once off fee of R8000.00 (excluding VAT) for a single application and R9000.00 (excluding VAT) for a joint Application.

2.2. 100% of the Debt Consellors Negotiation fee is payable at the first instalment.

2.3. Should a Debt Counsellor fail to draft proposals for the Credit Providers or refer the matter to a Tribunal or a Magistrate Court within 60 business days from date of the debt review application the Debt Counsellor has to refund 100% of the fee paid by the consumer (excluding the administration fee).

3. Cancellation Fee

3.1. Should the consumer withdraw from the process after the Debt Counsellor has drafted the proposals for the credit providers, a fee equal to 75% of the restructuring fee as per 3.1 above is payable by the consumer.

4. A monthly after-care fee payable to the DC.

4.1. 5% up to a max of R450 (excl VAT).Payment of the monthly after-care fee is to commence in the 2nd month after the amount in above has been paid.

5. Legal fees

5.1. A legal fee equal to a minimum of the proposed installment will be charged for all cases that are placed on the roll for hearing. This amount will come off of the second installment paid. And be calculated using the amount of Debt and Creditors involved in the application. (Eg. The higher the debt or the more creditors then the higher the legal fees involved). Should the matter be refered to the Tribunal then the charge is set at R500.

I the undersigned hereby confirm that I have read and understand this fees form and consent to any and all points contained herein.

Kindly take note that this fee structure is for a debt review application which is subject to change. The fee structure for an Administration order is unique to each applicant and can only be given once the application has been completed and assessed.

Declaration by Consumer

1 ) To undertake to comply with all requests from the Debt Counsellor to assist him/her to evaluate mystate of indebtedness and the prospects for responsible debt restructuring;
2 ) To hereby consent to the submission of my information to all registered Credit Bureaus by the Debt Counsellor;
3 ) To also consent that the Debt Counsellor may obtain my credit record from any/all registered Credit Bureaus and any other registers which may contain any of my credit information;
4 ) To undertake not to enter into any further Credit agreements, other than a consolidated agreement, with any credit provider until one of the following events has occurred:
a) The Debt Counsellor rejects my application;
b) The Court determines that I am not over-indebted; or
c) All my obligations under Credit Agreements as re-arranged are paid up and fulfilled.
5 ) I am aware that debt counselling fees are payable to a debt counsellor for services rendered and this includes payment of aftercare fees.
6 ) To agree for a Debit Order to be deducted from my bank account or a Stop Order deduction come off my salary, for monthly deductions by the NCR approved PDA (Payment Distribution Agency), who will distribute the monthly payments to my Creditors.
7 ) After fulfillment of my obligations and all fees have been paid, the Debt Counsellor will issue a Clearance Certificate to all Credit Bureaus and Credit Providers.
8 ) Should I elect to make direct payments to the credit providers, I will send proof of payment to the Debt Counsellor on a monthly basis for record keeping and to enable provision of after care services.
9 ) I will remain responsible for making all payments as re-arranged in full and on time. I am aware that making a short or late payment puts me at risk of termination or legal action by credit providers.
10 ) I understand that once a debt review court order has been obtained I cannot terminate or withdraw from the process unless I approach the court for a rescindment.
11 ) Where the Debt Counsellor has suspended provision of service, I will remain responsible to provide proof of settlement letters from credit providers in order for the debt counsellor ro issue a clearance certificate.
12 ) I understand that I must not sign any documentation I receive from any Creditor and shall make no promises, verbally or in writing, to any Creditor.
13 ) I confirm that I undestand and have had the contents of all these documents as well as the full debt review process explained to myself in a language that I understood.
14 ) I hereby appoint Shawn Davies NCRDC3115 who has his principle place of business at 296 JABU NDLOVU STREET, PIETERMARITZBURG, 3201. (“the Debt Counselor”) to be my true and lawful agent and I expressly grant the Debt Counselor full power of attorney and authority to, on my behalf:
· Cancel any debit orders; and / or
· Stop payments of any debit orders,
15 ) In order to facilitate the debt review in terms of section 86 of the National Credit Act 34 of 2005. Should it be found that I had previously applied for Debt review with a different Debt Counsellor I hereby request and consent to a transfer of my file to the above Debt Counselling Office.
16 ) That the information contained in this document is, to the best of my knowledge, true and correct.


“I agree that if the date of the payment instruction falls on a non-processing day (weekend or public holiday), the payment instruction may be debited against my account on the previous and/or following business day”
I agree to the tracking of dates to match with the flow of Credit at no additional cost to myself.
“I agree that the originator may make use of the tracking facility as provided for in the EDO system at no additional cost to myself.”
“Subsequent payment instructions will continue to be delivered in terms of this authority until the obligations in terms of the Agreement have been paid or until this authority is cancelled by me/us as below.”
I agree that the Debt Counsellor or NPDA may amend the monthly debit payment amount or submit a new payment instruction, at any time during a month, in order to collect any arrears (including agreed fees, costs or charges) on failed or reversed payment(s) against the agreed terms of the Agreement and this mandate, NPDA may submit to my creditors a request to return all distributions made to them under the Agreement;
“In the event that any stop payment instruction is made by me/us to my/our bank in order to reverse the monthly payment, I/we will immediately be in breach of this agreement and this breach may inter alia lead to the termination of the debt review arrangement with my/our creditors.”
“If either party breaches in any material respect any of the material obligations under this Agreement, in addition to any other right or remedy, the non-breaching party may terminate this Agreement in the event that the breach is not cured within (14) days after receipt by that party of written notice of the breach to its domicilium citandi et executandi and/or email address.”
“I cede this Debit Order Mandate to NPDA. If I/we fail to remedy my/our breach as contemplated above, I acknowledge that NPDA may upon such instruction provide my/our bank with this ceded Debit Order Mandate to counter my/our stop payment instruction. Alternatively, NPDA may collect directly or appoint any third party to collect on their behalf any amount due and I/we will be liable for all losses and costs on an attorney and own client basis to collect the outstanding amount.”
“I acknowledge that payments received by NPDA will first be allocated to any arrears (if any) and thereafter be distributed as per payment plan.”
“I agree to pay any charges relating to this debit order instruction and/or any other charges (including but not limited to attorney and own client costs) as a result of failed or reversed debit orders.”
“I agree that it is my responsibility to ensure that there are sufficient funds in my abovementioned account on the Salary Deposit Date.”
I agree to notify my Debt Counsellor prior to any submission of a dispute to my bank.
“This authority may be cancelled by giving the Debt Counsellor or NPDA 30 calendar days’ written notice, sent by prepaid registered post or delivered to the NPDA physical address indicated above. Such termination will not terminate the Agreement. Receipt of your notice shall be after the Debt Counsellor or NPDA has acknowledged receipt of your notice.”
“By signing this Mandate I acknowledge that the Debt Counsellor has explained to me the Agreement and this Mandate. I agree to notify the Debt Counsellor and NPDA in writing to immediately if any of the above details change.”


I/We acknowledge that this Mandate and authority may be ceded or assigned to a third party if the Agreement is also ceded or assigned to that third party. You will be notified of the assignment prior to any direct debit instruction by the assignee.