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Fields marked * are mandatory fields

You can download this form here and email it to if you have trouble with this online form.


Company Name*:

Full Name*:

Contact Person*:


Phone No*:


Your bank account number (for debtor repayments)*-  -  

Your Reference:


Company Name*:

Company's address*:

Contact Person*:


Contact Persons Position:

Mobile Phone No:    Phone No:

Any other information that may be of help collecting the debt i.e debtor's relatives contact details:

Upload photo of debtor:


Do you have a debt collection clause?
Select "Yes" if you have a debt collection clause in your terms of trade contract*  

Amount Owing $*:                                             

Court Order number:            

Date incurred/Invoice Date: 


Upload invoice/s:                   

Upload other docs:                

Have you previously attempted 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.

Additional photo's, docs, orders etc email them directly to us by clicking here - please include your reference in the subject line.

Click here for pricing options

I have read and understood CIA Debt Recovery Limited's terms and conditions*

Full Terms and Conditions PDF download 

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 current terms and conditions.

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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