Example: 27831231234
(no spaces between numbers). When you submit your input you will receive a sms
to confirm.
Provide your email address to receive your report.
Email:
Marital Status:
Number of kids ?(If Applicable)
To continue please click
(Page 2)
Select from Group/Employer drop-down
Group/Employer:
Membership/Account number:
Employers name:
Employee number:
To continue please click
(Page 2)
Tell us about your Financial profile
Describe your current debt profile:
How often do you gamble, "Including the National Lottery ?"
What form of gambling do you participate in ?
Casino Table Games
Casino Slot Machines
Lottery
Horse Racing
Bingo
Scratch Cards
Internet Gambling
Private Card Games
Dice
Limited Pay Out Machines
Fafi and Other Forms of Gambling
If you play the lottery, how many tickets on average do you
buy a month
When you participate in any form of gambling how much do you
usually take with you to gamble per visit.
Do you lose more than you can afford to when you gamble ?
Which of the following describes your current accommodation?
To continue please click
(Page 3)
Tell us more about how much money you earn each month
Use your payslip to complete this section (Only use figures e.g.:
1234.43 or 1234) (Monthly deduction only)
Your Income
Rand
Description
Income
Spouse/Partner
Nett income:
The amount after all deductions paid into your bank account
On your payslip find the
area that shows your monthly deductions. Next to the amount you will find a
description of the monthly amount deducted which is to be added.
Pension fund:
The amount on your payslip deducted for pension
Medical aid:
The amount on your payslip deducted for your Medical Fund or
Medical Insurance
Loans:
If more than one loan is deducted on your payslip add them
up and enter the total amount !
Union subscription:
The amount on your payslip deducted if you belong to a Union
Insurance:
The amount on your payslip deducted for Short Term Insurance
UIF:
The amount on your payslip deducted for UIF
Group Life:
The amount on your payslip deducted Group Life Insurance
RA'S/ Endowment:
The amount on your payslip deducted for retirement annuities
or endowment policies
Garnishees/ Admin Order:
The amount on your payslip deducted for any Garnishee or
Administration orders
Funeral Policy:
The amount on your payslip deducted for Funeral Policy. If
you have more than 1 add them up and write down the total amount
Other:
If there are any other amounts deducted on your payslip add
them up and write them down
Please specify what this deduction is for i.e. Canteen
Tax:
The amount on your payslip deducted for Tax.
Additional Income (Monthly income only)
Maintenance:
This monthly income will be included in your budget
Pension:
This monthly income will be included in your budget
per month.
Moonlighting (2nd Job):
This monthly income will be included in your
budget.
Family:
This monthly income will be included in your
budget.
Investments:
This monthly income will be included in your
budget.
Other:
This monthly income will be included in your
budget.
To continue please click
(Page 4)
Tell us how you currently spend
your money
Household expenditure
(Only use figures e.g.: 1234.43 or 1234) (Monthly expenditure only)
Monthly and /or Pre-paid phones in household (Telkom & Cell
Phones), Internet.
Security:
Security company, Protection , Netstar, Tracker.
Petrol/Travel:
Petrol, Vehicle service and maintenance, Train, Bus, Taxi,
Parking
Rates & Taxes:
Monthly Municipal Rates in Taxes, Body Corporate Levies
School Fees:
Monthly school fees, Boarding fees, Chrèche, Higher
education costs
Family Expenses:
Church , Charity, Pocket money, Maintenance, Hairdresser,
Dry cleaning, Chemist (non medical), Vet, Household Maintenance & Repairs, Pool,
Gifts, Bank Costs
Other:
Any other regular monthly cost not included above.
To continue please click
(Page 5)
Tell us how you currently spend
your money
Entertainment
You should include under "Entertainment" anything you spend money on for
pleasure. Entertainment includes what you spend on books, newspapers, movies,
television, eating out, going to café's or restaurants, bars and pubs, as well
as what you spend on alcohol, cigarettes, chocolates, home entertainment, etc.
It is very important to include under "entertainment" whatever money you lose on
average through gambling.
(Only use figures e.g.: 1234.43 or 1234) (Monthly expenditure only)
Going out
Restaurants, Movies, Theatre, Take-aways, etc.
Sports
Both watching and participating. Including TV, DSTV, M-Net,
Clubs, Gym, etc.
Any other regular monthly cost not included above. E.g.:
Magazines, Paper, Hobbies, TV Rental and social clubs.
To continue please click
(Page 6)
Tell us how you currently spend your
money
Financial Services
(Only use figures eg: 1234.43 or 1234) (Monthly amount paid only)
Services
Rand
Description
Assurance:
From your payslip (Populated from your input above)
Monthly Life & Endowment, Funeral Policy(Not on your
payslip)
Insurance:
From your payslip (Populated from your input above)
Monthly Short Term Insurance - House content, Vehicle(s)
(Not on your payslip)
Medical Aid:
From your payslip (Populated from your input above)
Monthly Medical Aid Subscriptions, Medical cost (Not covered
by medical aid), Medical Insurance, Hospital Plan (Not on your payslip)
Pension/Risk Benefit:
From your payslip (Populated from your input above)
Monthly Pension Fund contributions, Retirement Annuities
(Not on your payslip)
Other:
Monthly Educational Policy, Educational Savings, Regular
Bank savings, Unit trusts
To continue please click
(Page 7)
Tell us how you currently spend your
money
Debt Repayment
(Only use figures e.g.: 1234.43 or 1234) (Monthly amount due - not
full amount of debt)
Debt
Rand
Description
Credit Card:
Monthly amount due on all credit cards. If you have more
than one credit card add them up and enter the total amount.
Bond:
Monthly bond, Rent, Lodging payments.
Car Repayments:
Monthly Car and/or other vehicle repayments. If you have
more than one add them up and enter the total amount.
HP/Rental:
Monthly furniture and/or Appliances repayments and or
rentals (e.g.TV rental) If you have more than one add them up and enter the
total amount
In-Store Accounts:
Monthly amount due for clothing or other goods. If you have
more than one add them up and enter the total amount.
Other:
From your payslip (Populated from your input above)
Any regular debt repayment not mentioned above such as loans
from friends or family or work. If you have more than one add them up and enter
the total amount (Not on your payslip).
To continue please click
Please submit your input once by clicking the [Submit] button below. If you
have entered your cell phone number above you will receive a SMS to confirm that
your input has been received.