IRS DEBTOR QUESTIONNAIRE

PERSONAL DETAILS

Person 1

Person 2

First Name
Family Name
Tel.
Email
Marital Status
Date of Birth
PPSN
Address Line 1
Address Line 2
Town
County
Any previous address in the
past five years
No. of people in household

Adult

College

Secondary
School

Primary School

Pre-School

Infant

Per Week

Per Fortnight

Per Month

Per Week

Per Fortnight

Per Month

Children Ages

TEL. (058) 23511

INCOME DETAILS

Person 1

EMAIL. deniseobrien.irs@gmail.com

Person 2

TICK IF
INCLUDED

Employment - Gross
Employment - Net

WHEN RETURNING THIS FORM, PLEASE INCLUDE THE FOLLOWING DOCUMENTS

Self-Employment - Gross

1.) 3 months payslips and/or social welfare slips for all in household

Self-Employment - Net

2.) Last years P60, or self-assessment tax return if self-employed

Social Welfare

3.) 6 months bank statements on all active banks accounts

Pension

4.) Statements or demand letters for each debt that you owe

Contribution 3rd party

5.) A copy of your driving license and/or passport

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IRS DEBTOR QUESTIONNAIRE

PROPERTY ASSETS

Property type Current Market

detached / semiValue
D / apt / etc.

Mortgage
Amount

Mortgage payment
Mortgage payment
p/m as per
being paid
contract

Interest Rate

Number of
payments to end
of mortgage
term

Lender Name

Account Name

Account Name

Account Number

Account Number Your % ownership

Monthly Income Gross (from the

property)

Monthly Income Net (from the

property)

Interest Rate

Monthly Payment

Family Home (PPR)

Other Property 1
Other Property 2
Other Property 3
Other Property 4
Other Property 5

VEHICLES

Make

Model

Reg. Number

Mileage (KMs)

Value

Name of who
owns vehicle

Lender / Finance
Company

Value

Subject to Finance
(Y/N)

How much owed

Name of Lender

Lender's Ref.

Balance
Outstanding

Number of
Payment
remaining

Vehicle 1
Vehicle 2
Vehicle 3

OTHER ASSETS

Details

CASH /
DEPOSIT

Jewellery

Cash

Antiques

Deposit 1

Boat

Deposit 2

Other 1

Deposit 3

Amount

Bank / Building Society / Post Office

Name

Account No.

Value

Company Name

Pension Ref.

Other 2
PENSIONS
Other 3
Other 4

Policy 1

Other 5

Policy 2

Other 6

Policy 3

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IRS DEBTOR QUESTIONNAIRE

UNSECURED DEBTS / name(s)

of borrower(s)

Family background

Name of Lender

Amount Owed (net

Original Purpose of
Account Number
of shares for a CU)
Loan

Interest Rate

Number of months Original Payment

remaining
per contract

Current payment
being made

Is there a
Judgement?

Please write a brief note in these three boxes. If you want to give more detail, please feel free to continue on the back of this page. Thank you.

Employment background

Debt problem background

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IRS DEBTOR QUESTIONNAIRE

OTHER GENERAL INFORMATION

Are you, or have you been know by any other name (including maiden name):

Current marital status and any previous annulment:

Any previous addresses in the past 5 years:

If employed, what is your occupation and the name of your employer?

Length of Service with this employer:

Have you had any previous businesses in the past 5 years?

If you own a vehicle what is it's registration number

Vehicle value

Have you or anybody in your household any Special Circumstance Costs, and if so please list them:

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Mileage on vehicle