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TDA







Person proposing termination







Report from Debt Agreement Administrator
Please complete from a current administrator status report.

Date of administrator status report (not more than two months old and not a three month arrears default report)













YES


NO


NOT APPLICABLE

If no, please provide details

Has the debtor made arrangements to catch up arrears?

YES


NO


NOT APPLICABLE


Debtor/Creditor/Authorised Officer of Creditor I understand that where a debt agreement is terminated:
• the debts are reinstated after taking into account payments made under the debt agreement; and
• the debtor no longer has protection under the Bankruptcy Act and creditors are entitled to take action to recover their debt.





Return to Australian Financial Security Authority
PO Box 10443 Adelaide Street
Brisbane
Queensland 4000
Phone 1300 364 785 Fax
07 3360 5494 Email
debtagreementservice@afsa.gov.au

Explanatory Statement
Please indicate the reason for proposing this termination and provide information creditors should know.





Yes


Yes


Yes


Yes


Yes



Yes


Yes


Yes






Supporting statement








Changes in creditor name or address since debt agreement commenced
Creditor name on debt agreement proposal

Creditor name on debt agreement proposal


Nature of debt


1 CURRENT CREDITOR NAME


1 Current Creditor Postal Address / Email Address

2 Creditor name on debt agreement proposal


2 REFERENCE NUMBER


2 CURRENT CREDITOR NAME


2 Current Creditor Postal Address / Email Address

3 Creditor name on debt agreement proposal


3 REFERENCE NUMBER


3 CURRENT CREDITOR NAME


3 Current Creditor Postal Address / Email Address

4 Creditor name on debt agreement proposal


4 REFERENCE NUMBER


4 CURRENT CREDITOR NAME


4 Current Creditor Postal Address / Email Address

5 Creditor name on debt agreement proposal

5 REFERENCE NUMBER


5 CURRENT CREDITOR NAME


5 Current Creditor Postal Address / Email Address

Debtor/Creditor/Authorised Officer of Creditor I declare that the particulars set out in this statement are correct. Offence:
Section 267 of the Bankruptcy Act provides that a person must not sign a declaration that the person knows to be false.
Penalty:Imprisonment for 12 months





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