Form  17  ( 1/12/04)
Bankruptcy Act 1966		
Debt Agreement Statement of Affairs & Proposal		

Print name in full

     
Title  	     
Family name 	     
Given names 	

If you do not speak, read or write English, the Interpreting Service is available for the cost of a local call on 131450.

Contents of Statement of Affairs		Page
Part A – Personal Details
PART B - Your Income and Employment
Part C – Your assets
PART d – MONEY YOU OWE YOUR CREDITORS
Part e – BUSINESS, Company and Trust Details
DECLARATION
Checklist for Debt Agreement Statement of Affairs

Office Use Only 	Date Filed		
Event Number		
Administration Number		

Part A – Personal Details
	1      Your personal details
Gender	Male 	     	Female	     
List all other names used in the last 10 years	     	
	     	
	     	
Date of Birth	      /       /      
     
     	
Residential address	     	
	     	Postcode	     	
Do you own or are you buying this property?	No      	Yes       please give details
Postal address	     	
	     	Postcode	     	

Telephone	Home (       )       	Work (       )      
 	
	Mobile      	Fax (       )      	
Email Address	     	
Do you prefer to receive correspondence by email where possible? 	No      	Yes      
Previous address
     	
     	Postcode	     	
Do you have a current driver's licence? 	No      	Yes       please give details
Licence number	     	
Expiry date	      /       /      	
State of Issue	Australia	     	Other	     	
What language do you commonly use at home?
English	     	Greek	     	Arabic 	     	Serbian	     
Croatian	     	Italian	     	Vietnamese	     	Other	     
	2       Spouse / Partner
Do you have a spouse/partner?	No      	Yes       please give details
Your spouse/partner’s full name	     	
What is your spouse/partner’s separate gross income	$      	per year OR	$      	per week	
	3       Dependents
How many people are dependent on you for financial support?	     
	4       Legal Actions / Proceeds of Crime
4a. Are you involved in any legal actions with any creditors?	No      	Yes      
4b. Are you or your property subject to a 
Proceeds of Crime Order?	No      	Yes       Provide a copy of the order
	5       Cause of your financial difficulties
What do you believe is the main cause of your insolvency? 
Tick one cause only in either 5A or 5B that best describes the main cause of your financial difficulties.  
5A	Non Business Related
     	Unemployment or loss of income
     	Adverse legal action
     	Liabilities due to guarantees
     	Gambling, speculation & extravagance in living
     	Ill health or absence of health insurance
     	Domestic discord or relationship breakdowns
     	Excessive use of credit facilities including losses on repossessions, high interest payments and pressure selling

5B	Business Related (only applies if you have personally operated a business)
     	Economic conditions affecting industry, including competition, credit restrictions, fall in prices or increases in costs
     	Lack of business ability including underquoting or failure to assess potential of business
     	Excessive interest payments on loan monies and capital losses on repayments
     	Excessive drawings including failure to provide for taxation
     	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 initial working capital
     	Gambling or speculation
     	Seasonal conditions including floods and drought
If other reason not listed please specify.
     	

6. Are you currently up to date with payments to your creditors? 	No      	Yes      
7. When were you last able to pay your debts as they fell due?	Month      	Year      
8. Who provided you with information about bankruptcy and the alternatives? (tick one only)
ITSA	     	Financial Counsellor	     	Accountant	     
ITSA pamphlets	     	Registered Trustee	     	Solicitor	     
ITSA website	     	Debt agreement consultant/administrator	     	Other	     

9. In the past 10 years have you been bankrupt, been party to a debt agreement as a debtor
 or given an authority under Section 188 of the Bankruptcy Act?

	No      	Yes       	Year      

PART B - Your Income and Employment
10	Summary of your income
Source of income	Received from	Income received during the 
last 12 months	Income likely to be received during the 
next 12 months	
Government benefits/ pension - payment type	     	$     	$     	
Gross wages & salary
before tax
(include allowances)	     	$     	$     	
Income from a business	Business name       	$     	$     	
Income from a trust	     	$     	$     	
Company dividends 	     	$     	$     	
Any other source	     	$     	$     	
	Total income before tax	$     	$     	
	Less income tax and Medicare levy	$     	$     	
	Total income after tax and Medicare levy	$     	$     	

Attach - evidence of your income, eg payslips, tax returns.

	11	Occupation
What is your usual trade or profession?	     	

	12	Employment Status
Are you currently employed?	No      	Yes       Go to Q13

How long have you been unemployed?	Years      	Months       Go to Q14

	13	Current Employment
Employer	Job 1		Job 2	
Name	     		     	
Address	     		     	
	     		     	
Employed as	     		     	
Nature of employer’s business	     		     	
Type of Industry	     		     	

Part C – Your assets 
	14	Assets
List your assets
Description of Asset	Jointly owned
Yes/No		Value 
(if jointly owned, insert your portion)	
Cash	     	$	     	
Cash deposits	     	$	     	
House, land, building
(only disclose assets which are owned outright)	     	$	     	
Car (only disclose assets which are owned outright)	     	$	     	
Boat 	     	$	     	
Caravan 	     	$	     	
Shares 	     	$	     	
Managed investments	     	$	     	
Insurance bonds	     	$	     	
Jewellery	     	$	     	
Money owed to you	     	$	     	
Business assets	     	$	     	
Capital distribution from a trust	     	$	     	
Assets you own which are in somebody else’s possession	     	$	     	
Furniture, household items	     	$	     	
Interest in deceased estate.
(Only include if you have been formally advised by an executor that you are a beneficiary under a will and will receive a distribution under the terms of the will)	     	$	     	
Any other items of value-please list below	     	$	     	
     	     	$	     	
     	     	$	     	
     	     	$	     	
     	     	$	     	
     	     	$	     	
     	     	$	     	
	Total	$	     	

Please copy this page if you have more than 3 secured creditors.

PART d – MONEY YOU OWE YOUR CREDITORS
	SECURED CREDITORS
15	Secured Creditors - (Creditors who are not secured should be listed at Question 16)
List your secured creditors.
A secured creditor is a creditor who can repossess and sell your asset/s if you fall behind with your payments. For example, a mortgage over your house, a hire purchase/lease agreement over your vehicle, a chattel mortgage or a bill of sale over your business assets.

(Note: Certain debts are not released under a Debt Agreement; please refer to your Prescribed Information booklet for more details.)

	Secured Creditor No. 1		Secured Creditor No. 2		Secured Creditor No. 3	
Creditor’s name	     		     		     	
Creditor’s postal address	     		     		     	
	     		     		     	
Account/Loan number	     		     		     	
Total amount owing to this creditor	$	     			$	     			$	     		
Type of security (eg mortgage)	     		     		     	
Date the security was given	     	     	     			     	     	     			     	     	     		
Description of secured asset	     		     		     	
Location of asset	     		     		     	
Estimated resale value of the asset	$	     			$	     			$	     		

Is it a joint loan?	No	     	Yes	     		No	     	Yes	     		No	     	Yes	     	
Are loan repayments up to date?	No	     	Yes	     		No	     	Yes	     		No	     	Yes	     	
Has the creditor repossessed the asset?	No	     	Yes	     		No	     	Yes	     		No	     	Yes	     	
Is this creditor related to you?	No	     	Yes	     		No	     	Yes	     		No	     	Yes	     	
Related Creditors.  If you are unsure whether a creditor is related, please refer to the information sheet accompanying this form before answering this question. 
Related creditors must be disclosed by ticking the yes or no box.
	
16	Unsecured Creditors

Please copy this page if you have more than 10 unsecured creditors.

List your unsecured creditors. (An unsecured creditor is a creditor who does not hold security over any particular asset you own.) Include all debts that have not already been listed as secured at Q15.  (Debts include loans from friends and relatives, personal guarantees and contingent debts.)
Related Creditors  If you are unsure if a creditor is related, please refer to the information accompanying this form before answering this question. 
Related creditors must be disclosed by circling Yes or N.
Creditor Name	Full postal Address	Nature of debt	Account No.	Mth/Yr Incurred	Total amount
owing	Related Party?	Joint
debt?	
1      	     					No	No	
     	     	     	     	     	     	     	Yes	Yes	
2      	     					No	No	
     	     	     	     	     	     	     	Yes	Yes	
3      	     					No	No	
     	     	     	     	     	     	     	Yes	Yes	
4      	     					No	No	
     	     	     	     	     	     	     	Yes	Yes	
5      	     					No	No	
     	     	     	     	     	     	     	Yes	Yes	
6      	     					No	No	
     	     	     	     	     	     	     	Yes	Yes	
7      	     					No	No	
     	     	     	     	     	     	     	Yes	Yes	
8      	     					No	No	
     	     	     	     	     	     	     	Yes	Yes	
9      	     					No	No	
     	     	     	     	     	     	     	Yes	Yes	
10      	     					No	No	
     	     	     	     	     	     	     	Yes	Yes	
Note: You may not be released from certain debts, refer to Provable Debts in your Prescribed Information booklet for more details.	TOTAL	$      			

Part e – BUSINESS, Company and Trust Details
	17	Sole trader/Partnership
Are you currently in business as a sole trader or in partnership?  	No         Go to Q18
	
	Yes       please give details

Business Name	     	
Business Address	     	
Business Partner’s name (if applicable) 	     	
What is the nature of this business?	     	
When did the business start operating?	      /       /      	

Have you sold any business assets in the past 2 years? 	No      	Yes       please give details
Business Name/Asset Description	Date Sold	Name of Purchaser	Amount Received	
     	     	     	$	     	
     	     	     	$	     	
     	     	     	$	     	
	18	Companies
Have you been a director or had a management 
role in a company at any time in the last 2 years?     No        Go to Q19	  Yes       please give details

Company Name	     	
Registered Address	     	
	     	
Trading Name	     	
Nature of company activity	     	
Have you sold any shares in this company the last 2 years? 	No      	Yes       please give details
No. of shares	Date sold	Sale proceeds	
     	      /       /      	$	     	
     	      /       /      	$	     	
If the company has ceased trading, is it in liquidation or under administration? 	No      	Yes       
	19	Trusts
Have you been a unit holder in or beneficiary of a trust in the last 2 years; OR
Have you transferred any assets to a trust in the last 2 years?
	   No        Go to page 9	Yes       please give details
Trust Name	     	
Trustee’s Name	     	
Trustee’s Address	     	
	     	
Has the trust made any income or 
capital distribution in the last 2 years? 	     No      	Yes       please give details
If yes did you receive a distribution? 	     No      	Yes       details must be included at Q10 & 14
DECLARATION
Complete the Declaration below:

Note:	Section 267(2) of the Bankruptcy Act 1966 provides that a person must not sign a declaration that the person knows to be false.
Penalty:	Imprisonment for 12 months.

I acknowledge that I have received and read the Prescribed Information 
published by the Insolvency and Trustee Service Australia (ITSA) which sets out the consequences of entering into a debt agreement.

I declare that the particulars set out in this statement are correct.
Signature	Date       /       /      	

Note: The documents must be filed with ITSA within 14 days of signing or they will be returned.

If you received assistance completing this form, the person providing the assistance should sign the statement below.

To be completed by any person or interpreter who assisted a person to complete this form.
Signature	Date       /       /      	

Full Name	     	
Address	     	

Reason the person required your assistance?	
     	

	
Checklist for Debt Agreement Statement of Affairs

1.	Please check you have answered every question in Parts A, B, C, D and E.
2.	Please ensure Related Creditors have been identified at Questions 15 & 16
3.	Attach evidence of your income as requested at Question 10

Now continue to Question 1 on the Debt Agreement Proposal form attached.

	
NOTES:       

PART P

Office Use Only			
Debt Agreement Proposal	

I/We offer this Debt Agreement Proposal to my/our creditors pursuant to Part IX of the Bankruptcy Act 1966.
Each person included in this proposal must complete an individual Debt Agreement Statement of Affairs.
1	Person 1   Personal details 

Family name	     	
		
Given names	     	
		
Residential address	     	
	     	Postcode          	
			
Postal address	     	
	     	Postcode          	

Person 2   Personal details (To be completed if lodging a joint proposal)	
Family name	     	
		
Given names	     	
		
Residential address	     	
	     	Postcode          	
			
Postal address	     	
	     	Postcode          	

2	Cause of my insolvency and supporting information I want to make known to my creditors.  
Explain the circumstances which led to you not being able to pay your debts as they fell due. Describe any change in your circumstances that contributed to your present financial difficulties.	
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	

3	Income and living expenses.

Income from all sources after tax and Medicare levy 
tick the period that the following income/expenses refer to		Weekly	
		Fortnightly	
		Monthly	
Your pay after tax and Medicare levy	$	     	
Average Centrelink benefit/pensions payment	$	     	
Maintenance received 	$	     	
Other sources of income	$	     	
A   Total income after tax and Medicare levy 	$	     	
Expenses 				
Rent or mortgage payments	$	     	
Rates	$	     	
Food	$	     	
Phone/s, mobile/s, internet, cable TV	$	     	
Electricity, gas	$	     	
Medical insurance	$	     	
Medical/chemist	$	     	
Car payments to secured creditor	$	     	
Car fuel, registration, insurance	$	     	
Transport expenses	$	     	
Other insurance 	$	     	
School fees and expenses	$	     	
Child care	$	     	
Child support, and maintenance payments	$	     	
Other expenses for your children, e.g. sport, music lessons, presents, clothes etc.	$	     	
Clothes, shoes/hairdressers etc.	$	     	
Incidentals – entertainment, alcohol, cigarettes, books, magazines, takeaways etc.	$	     	
Other expenses	$	     	
B   Total expenses	$	     	
Uncommitted income.
(Total income after tax and Medicare levy(A) less Total expenses(B))	$	     	

4	Detail below what property or income is being offered under the proposal. 
The property or income offered to creditors may include making periodic payments from uncommitted income, the transfer or sale of property, a lump sum payment, a delay on repayments for a period or some other arrangement. 

If the proposal involves making periodic payments, please detail below.	Total value of property / payments
	
No. of payments	Weekly/fortnightly/ monthly	Amount of each payment		
     	     	$	     	$	     	
     	     	$	     	$	     	
     	     	$	     	$	     	
     	     	$	     	$	     	
If the proposal involves the transfer or sale of property, a lump sum payment etc please detail below.			
     	$	     	
     	$	     	
If the proposal involves a delay on repayments for a period or some other arrangement please detail below.			
     	$	     	
     	$	     	
     	$	     	
A    Total value of property/payments  to be dealt with under the proposal	$	     	

5	Expected distribution of income or property by the administrator.
Detail below how much of the income or property being offered is to be paid to the administrator for costs and fees and how the balance is to be distributed to each creditor. 

Fees for putting terms of the agreement into effect	$       	
Expenses and disbursements of administrator	$       	
B    Total fees, expenses and disbursements	$       	
Unsecured creditors	Is this creditor related? Please circle Yes/No
	Total amount of debt unsecured 

$	Date dividends start
	Cents
in each
dollar
for
creditors
	Frequency
of dividends
eg quarterly/
half-yearly 
	Total amount to be paid to unsecured creditors 

$	
							
     	Yes/No	     	     	     	     	     	
     	Yes/No	     	     	     	     	     	
     	Yes/No	     	     	     	     	     	
     	Yes/No	     	     	     	     	     	
     	Yes/No	     	     	     	     	     	
     	Yes/No	     	     	     	     	     	
     	Yes/No	     	     	     	     	     	
     	Yes/No	     	     	     	     	     	
     	Yes/No	     	     	     	     	     	
     	Yes/No	     	     	     	     	     	
     	Yes/No	     	     	     	     	     	
     	Yes/No	     	     	     	     	     	
     	Yes/No	     	     	     	     	     	
     	Yes/No	     	     	     	     	     	
     	Yes/No	     	     	     	     	     	
     	Yes/No	     	     	     	     	     	
     	Yes/No	     	     	     	     	     	
C    Total amount to be paid to creditors	     	
Total of B and C in question 5 to agree with A in question 4	     	

6	List all creditors who will not be paid by the administrator. 
(Include secured creditors where you intend to keep an asset and maintain contractual payments)	

Creditor’s name	Payments to be made direct to each creditor	Details of assets held by creditors as security.
Include an estimate of their market value and include an estimate of the amount owed to the creditor	
     	$	     	     	
     	$	     	     	
     	$	     	     	
     	$	     	     	
     	$	     	     	
     	$	     	     	
     	$	     	     	

7	List all assets, excluding normal household furniture and personal effects, that are owned outright and which are to be retained.

Description of Asset	Jointly owned
Yes/No	Estimated market
value of asset	
     	     	$	     	
     	     	$	     	
     	     	$	     	
     	     	$	     	
     	     	$	     	

I understand that proposing a debt agreement will be permanently recorded on the National Personal Insolvency Index (NPII) and that the NPII data including my name (including previous names and aliases) and address (including the business address and previous addresses) will be made available to private credit reference agencies which maintain records of a person’s credit worthiness for up to seven years.	Yes  	

I appoint and authorise the debt agreement administrator identified below to act as my agent in seeking access to information held by creditors about me and to give and receive personal information in connection with my financial affairs.	Yes  	

Signature of the Debtor	Date       /       /      	

Questions 8 and 9 are to be completed by the administrator
	
8	The costs and fees set out in Question 5 will be taken by the administrator according to the following schedule.  Costs and fees must not be taken in advance of work actually performed by the administrator.

     	
     	
     	
     	
     	
     	
     	
     	
     	

9	Details of debt agreement administrator.

Administrator’s name       	
Address       	
Phone        	Fax        	
Email address       	
Contact       	

I consent to act as administrator under this proposal and certify that I am not ineligible to act as an administrator in accordance with Regulation 9.04 of the Bankruptcy Regulations.

Signature of Administrator	Date       /       /      	

The completed Debt Agreement Statement of Affairs and Debt Agreement Proposal should be forwarded to an ITSA office. Addresses are listed on the back page of the Prescribed Information.