Financial Hardship Application – Merchant Finance Limited

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Customer Details

Account Number / Vehicle Reg.*

Account Name*

Date

Residential Address

Postal Address

Email address

Telephone

Mobile

This Request

Why are you applying for financial hardship assistance? (Tick which is applicable)

Loss of employment

Experience a reduction in income

Suffering an illness or major injury

Other significant event that has affected my income. Please provide details.

We will need you to provide further information which may include:

ID (Passport copy / Driver's License or Joint TIN Card)*

Proof of unemployment/reduced hours/reduced pay from employer

Proof of medical illness/injury

Evidence of additional income (i.e. rental income, benefits, boarder income).

Last 3 months’ statements for all bank accounts.

Last 6 months’ statements for any loans with other banks, finance companies or stores (i.e. credit cards, personal loans, hire purchases).

Repayment arrangements with other Financial Institutions

Evidence that insurances are paid and up to date.

I/We hereby declare that the information in this application and all attachments for financial hardship assistance is true and accurate and Merchant Finance Pte Limited is authorized to carry out any further checks.

Signature*

Date*

Financial Details

Monthly Net Earnings

Applicant 1

Applicant 2

Other Income

Total Monthly Earnings

Less Monthly Living Costs

Rent

Electricity

Telephone

Water

Housekeeping

School fees

Travelling/Petrol/Bus

Entertainment/Video

Hire Purchase

Courts

Carpenters Finance

Kontiki Finance

Home & Living

Other Hire Purchase

Other Loan Payments

Total Outgoings

Surplus Funds

MFL Monthly Repayments

Surplus Available

Net Weekly Surplus

Income Debt Ratio

Dependents

Name

Age

Name

Age

Name

Age

This field should be left blank