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

First Name*

Surname*

Address*

Email*

Phone Number

Mobile Number

Company  

Trading As

Bank Number*

 -   -   -    (For debtor payments to be paid into)

Your Reference
       
DEBTOR DETAILS

   

First Name*

Surname*

Middle Name

Gender

Debtor's current address

Date of Birth

  (Enter in as XX/XX/XXXX format) Email
Mobile Phone   Phone Number

Employer

Employers Phone

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 2 DETAILS

First Name

Surname

Middle Name

Gender

Debtor's current address

Date of Birth

  (Enter in as XX/XX/XXXX format) Email
Mobile Phone   Phone Number

Employer

Employers Phone

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 3 DETAILS

First Name

Surname

Middle Name

Gender

Debtor's current address

Date of Birth

  (Enter in as XX/XX/XXXX format) Email
Mobile Phone   Phone Number

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 

   

DEBT DETAILS

Amount Owing $*                                                 

Invoice number(s)                   

Date incurred/Invoice Date       (Enter in as XX/XX/XXXX format)

Reason for this debt/dispute

Do your terms of trade have a debt collection clause*   

Upload invoice           

Upload invoice           

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 to view Pricing Options


I have read and understood CIA Debt Recovery Limited's full Terms of Engagement*  

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 of Engagement.

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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