Registrar's examination - individual55 http://www.ucprforms.lawlink.nsw.gov.au/ucprforms/index.html

Form 55 (version 1)
UCPR 38.5
REGISTRAR'S EXAMINATION – INDIVIDUAL
COURT DETAILS
Court

#Division

#List

Registry

Case number

TITLE OF PROCEEDINGS
[First] plaintiff
[name]
#Second plaintiff #Number of plaintiffs (if more than two)



[First] defendant
[name]
#Second defendant #Number of defendants (if more than two)

JUDGMENT DETAILS
Judgment creditor
[name] [role of party]
Judgment debtor
[name] [role of party]
[This form may be used when a registrar conducts an examination under UCPR 38.5(2).  The form can be adapted as necessary to meet the requirements of the particular examination.]
Record of examination
INCOME (weekly unless otherwise stated)
Your average weekly income after tax from salary or wages
$

Social security benefits/pensions (include family payments etc)
$

All other income (eg self-employed income, interest, dividends, rent or trust distributions)
$




TOTAL
$




EMPLOYMENT DETAILS
What is the name of your employer?

What is the address of your employer?

SUBURB
POSTCODE
Is your salary or wage paid by your employer into an account in a bank or financial institution?

If you answered yes to the previous question, identify the institution, branch, BSB and account number.


PROPERTY OWNED BY YOU


CURRENT VALUE
Home
PROPERTY ADDRESS
$

VALUE OF EQUITY, IF ANY
$

Other property
PROPERTY ADDRESS
$

VALUE OF EQUITY, IF ANY
$

Funds in banks/ financial institutions, including funds held in off-set accounts
INSTITUTION, BRANCH, BSB AND ACCOUNT NUMBER
$




INSTITUTION, BRANCH, BSB AND ACCOUNT NUMBER
$



Investments
NAME AND TYPE OF INVESTMENT
$



Motor vehicle
YEAR
MAKE
$

MODEL
REGISTRATION NO

Household contents

$
Other personal property
DESCRIPTION AND LOCATION
$
TOTAL VALUE OF PROPERTY OWNED BY YOU
$
[Add extra lines, if necessary, so that all details of income and assets are disclosed.]
LIABILITIES
Average weekly expenses:

Other liabilities:
ITEM
WEEKLY AMOUNT

LIABILITIES
NAME OF BANK/INSTITUTION
TOTAL AMOUNT OWED
Food
$

Home mortgage

$
Household supplies
$

Other loans

$
Mortgage/rent
$

Credit cards

$
Gas
$

Credit cards

$
Electricity
$

Other liabilities
(specify)

$
Heating fuel
$




Rates/levies
$

TOTAL

$
Telephone
$




Motor vehicle





• Petrol
$




• Maintenance
$




• Registration/insurance
$




Medical/hospital funds
$




Other insurance (specify)
$




Fares
$




Clothing and shoes
$




Entertainment/hobbies
$




Education/childcare expenses, including fees and levies
$




Medical/chemist /pharmaceutical
$




Hire purchase payments
$




Credit cards
$




Other necessary commitments, including weekly payments on other liabilities, listed above (specify)
$




TOTAL WEEKLY EXPENSES
$
[Add extra lines, if necessary, so that all details of weekly expenses and liabilities are disclosed.]
Does anyone contribute to paying these liabilities (eg your spouse/partner)?
 Yes  No
If yes, give the person's details:

Name of person

Amount of contribution per week

Do you have any dependants?
 Yes  No
If yes, give details:

ADDITIONAL QUESTIONS REGARDING FINANCIAL CIRCUMSTANCES
Do you have any income, assets or liabilities not disclosed in this record of examination?

If you answered yes to the previous question, give details of the other income, assets (including their location) or liabilities.





What arrangements are you prepared to make to pay this debt?




#Additional questions






DOCUMENTS PRODUCED AT EXAMINATION
The following documents were produced at the examination:
1 [ ]
2 [ ]
[on separate page]
AFFIDAVIT
Name

Address

Occupation

Date

I [#say on oath #affirm]:
1 I am the judgment debtor.
2 I believe that the information contained in this record of examination about my present income, assets and liabilities is true.
#SWORN #AFFIRMED at

Signature of deponent

Signature of witness

Name of witness

Address of witness

Capacity of witness
[#Justice of the peace #Solicitor #Barrister #Commissioner for affidavits #Notary public]
Note : The making of a false statement or the giving of false information in an affidavit is perjury and is an offence punishable by law under the Oaths Act 1900 (NSW).
SIGNATURE OF REGISTRAR
#The judgment debtor has verified the answers to the questions by affidavit and provided the documents listed above.
#The judgment debtor answered the questions under oath and provided the documents in the course of the examination.
The examination has been held and is concluded.
Date of examination

Held at

Signature

Date