Consumer icon Load Consumer Debt

Fields marked * are mandatory fields
 
 
You can download this form here and email it to admin@cia.nz if you have trouble with this online form.

YOUR DETAILS

Company*:

Full Name*:

Contact Person:

Email:

Phone No*:

Address*:

Bank Account Number (for debtor repayments)*-  -  

Your Reference:

 

 
DEBTOR DETAILS

First Name*:

Surname*:

Middle Name:

Gender*:

Debtor's current address:

Date of Birth:

Email: 

Mobile Phone No:    Phone No:

Employer:

Employers Phone No.

Debtor's previous addresses (if known):

 

Other information that may be of help collecting the debt

i.e debtor's relative's contact details:

Upload a photo of the debtor: 

   
DEBTOR DETAILS

First Name*:

Surname*:

Middle Name:

Gender*:  

 

 

Date of Birth:

Email:   

 

 
Mobile Phone No:    Phone No:

Employer:

Employers Phone No.

 

Debtor's current address (if known):

Debtor's previous addresses:

Other information that maybe of help collecting the debt

i.e debtors relatives contact details:

DEBTOR DETAILS

First Name*:

Surname*:

Middle Name:

Gender*:  

 

 

Date of Birth:

Email:   

 

 
Mobile Phone No:    Phone No:

Employer:

Employers Phone No.

 

Debtor's current address (if known):

Debtor's previous addresses:

Other information that maybe of help collecting the debt

i.e debtors relatives contact details:

DEBT DETAILS

Amount Owing $*:                                              

Invoice number/s:                  

Date incurred/Invoice Date: 

Do your terms of trade have a debt collection clause*:  

Upload invoice/s:                   

Upload other docs:                

Have you previously attempted to enforce this debt via the Courts?*  

If you have previously started any Court action on this debt, or paid any Court fee's towards this debt, please state what was applied for, the fee/s you paid, and the Court enforcement application numbers (if any). This will help us to ensure we recover everything that is owed to you.

If you have additional photo's, documents, Court orders etc, please email them directly to us at admin@cia.nz 

  Click here for pricing options

I have read and understood CIA Debt Recovery Limited's terms and conditions*

By accepting these terms, you agree to authorise CIA Debt Recovery Ltd to act as your agent in the above matters and agree to make payment of all charges and costs in accordance with the terms and conditions.

You agree to not proceed to legal action, nor take independent action by another means through an agency or, on your own accord, against this debtor without first consulting CIA Debt Recovery Ltd. 

If you do take independent action or/and if any monies are paid to you or your agent, by the debtor, CIA Debt Recovery Ltd will invoice you for the full commission that relates to the option you have chosen above and any subsequent enforcement costs.

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