Repayment in instalments

Proposed repayment arrangement

File reference number

You can submit a suggestion for a repayment arrangement below. Arrangements will only be processed if the form has been filled in completely. Together with our client we will assess whether an arrangement is possible, and if so, whether your suggestion is approved.

Amount per instalment

Starting from

The 1st payment must be received by us within 2 weeks.

Repayment Per weekPer month

1. Personal data

Surname

Street and house number

Postal code

Place of residence

Date of birth

Telephone number

E-mail address

2. Income

Name of employer / agency paying the benefit

Place of business of employer / agency paying the benefit

Net income

You receive this amount per: Week4-weeksMonth

Other income

Amount of allowances

Such as a provisional refund, tax credits, child-related budget and healthcare and rent allowance.

3. Other

Amount of other debts

Preferential debts

Where do you have other debts?

Amount of rent / mortgage

Per month

Amount of the healthcare premium

Per month

Number of children living at home under 18 years of age

4. Partner

Do you have a partner with whom you live together? YesNo

Name of employer / agency paying the benefit

Per month

Net income of partner

Per month

Amount of the healthcare premium of partner

Per month

5. Additional information

Remarks

You can add additional information below, if required (max. 2,000 characters).

Attachment

Upload evidence, such as a bank statement showing your (and your partners) salary / benefit, allowances, housing costs, etc.

Attachment

Upload extra evidence.

* Required fields

We may need additional evidence for the assessment of your suggestion. If this is the case, we will inform you of the evidence we require.

Warning

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Proposed repayment arrangement

1. Personal data

2. Income

3. Other

4. Partner

5. Additional information

What happens next?