Debt query assessment form Debt query assessment form PART I: Prescription Claim First Name * Last Name * Creditor * Creditor's account number * MBD Reference Number * Identification Type SA ID SA Passport Other If "Other" please supply details ID or Passport number * Email Address * Cell Phone Number * Alternate Telephone Number * PART II: Prescription Assessment Do you know the original date of the contract? Yes no If ‘yes’, when: i) Contact: Have you ever been contacted in relation to this debt previously? * Yes No If yes, when Have you or did you sign any document acknowledging this debt?* Yes no If yes, when Did you receive Summons or any Legal document in relation to this debt? Yes no If yes, when ii) Payment: Are you currently employed?* Yes no Have you made any payment towards this debt? Yes no If yes, when Have you or did you make any payment arrangement in relation to this debt? Yes no Have you ever been out of the country for an extended period in the last 10 years? Yes no If yes, please provide details. To your knowledge, is this account paid up? Yes no reCAPTCHA *Mandatory fields If you are human, leave this field blank.