Surname

Title Mr/Mrs/Ms

Given Name/s

Person proposing termination
Debtor/Creditor Name

Postcode

Contact Number

Postal Address

Email Address

Contact Person

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)
Date of Administrator status report

Date of debtor’s last payment to administrator

Total arrears

Realisations charge paid to Australian Government

Fees paid to administer debt agreement

Allowable expenses paid to third party

Total dividends paid to creditors

Balance on hand with administrator

Total payments plus balance

Total receipts from debtor

Total receipts from sale of asset

Total receipts

If the proposal involved sale of property, has the property been sold?
YES

NO
NO

NOT APPLICABLE
NOT APPLICABLE

If no, please provide details

Has the debtor made arrangements to catch up arrears?
YES
YES

NO
NO

NOT APPLICABLE
NOT APPLICABLE

If yes, please provide details

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.

Name (please print)

Position (if creditor)

Signature

DATE SIGNED

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.

Debtor has ceased payments and is unlikely to recommence

Significant undisclosed unsecured debts

Significant understatement of unsecured debts

Significant undisclosed income or assets
Yes

Unemployment/Redundancy
Yes

Loss of income
Yes

Unexpected medical expenses
Yes

Loss of supporting payments eg. free board
Yes

Increase in number of dependants

Relationships breakdown and separation
Yes

Incurred significant post debt agreement debts
Yes

Other:
Yes

please specify

Supporting statement
Other information creditors need to know)

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

Creditor name on debt agreement proposal
1

Nature of debt
1 REFERENCE NUMBER

1 CURRENT CREDITOR NAME
untitled70

1 Current Creditor Postal Address / Email Address
untitled75

2 Creditor name on debt agreement proposal
untitled61

2 REFERENCE NUMBER
untitled66

2 CURRENT CREDITOR NAME
untitled71

2 Current Creditor Postal Address / Email Address
untitled76

3 Creditor name on debt agreement proposal
untitled62

3 REFERENCE NUMBER
untitled67

3 CURRENT CREDITOR NAME
untitled72

3 Current Creditor Postal Address / Email Address
untitled77

4 Creditor name on debt agreement proposal
untitled63

4 REFERENCE NUMBER
untitled68

4 CURRENT CREDITOR NAME
untitled73

4 Current Creditor Postal Address / Email Address
untitled78

5 Creditor name on debt agreement proposal
untitled64

5 REFERENCE NUMBER
untitled69

5 CURRENT CREDITOR NAME
untitled74

5 Current Creditor Postal Address / Email Address
untitled79

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

Signature

Name (please print)

Position (if creditor)

Date signed