Financial statement of judgment debtor
INDIVIDUAL
Court reference number (judgment/order number) Civil proceeding between
Full name (of judgment creditor) and Full name (of judgment debtor) A financial statement shows the judgment debtor’s financial situation.
Use this form if the judgment debtor is an individual. If the judgment debtor is an organisation, use form 36a
‘Financial statement of judgment debtor (organisation)’ instead.
Who can fill in this form?
You can only sign this form if you are the judgment debtor or their lawyer. Anyone can help you complete the rest of
the form.
1.
Provide your details
Full name Date of birth Postal address
Street address (if different)
Email Phone: Mobile Business MOJ36/05/14 Ministry of Justice Collections Unit www.justice.govt.nz/fines/civil-debt 0800 233 222
Home (if applicable) PAGE 1 OF 6
2. Provide details of your income
Are you working?
Yes
No
If you are working, please fill in the employment details below
Occupation
Employer
Address
Phone
Email
If you receive a benefit, fill in the details below
Benefit type
Benefit number
If you do not receive any income, please explain why (for example, supported by family)
Income
Frequency
Weekly
Fortnightly
Monthly
Amount after tax
Salary/wages$ Benefit$ ACC
$ Child support
$ Tax credits
$ Other income (please specify)
$ $ $ Total income $ MOJ36/05/14 Ministry of Justice Collections Unit www.justice.govt.nz/fines/civil-debt 0800 233 222
PAGE 2 OF 6
3.
Provide details of your expenses
Enter your expenses in the table below.
If these expenses are shared by several people, only include your contribution. Do not include debts, hire
purchases, loans or credit card payments in this section.
Frequency
Weekly
Fortnightly
Monthly
Amount
Rent/mortgage/board (select one)$ Food and household expenses
$ Electricity and heating (such as gas or wood)$ Home phone
$ Mobile phone
$ Internet$ Rates
$ Insurance$ Health costs (such as medical or dental)$ Child support
$ Childcare and education
$ Vehicle costs (such as warrant of fitness or vehicle registration)$ Transport costs (such as petrol, taxi, or public transport)$ Entertainment$ Other expenses (please specify)
$ $ $ Total expenses $ MOJ36/05/14 Ministry of Justice Collections Unit www.justice.govt.nz/fines/civil-debt 0800 233 222
PAGE 3 OF 6
4. Provide details of your assets
Value
Own home
$ Savings$ Voluntary superannuation payments
$ Investments (please specify)
$ $ Other property (please specify addresses)
$ $ Any other assets (please specify)
$ $ Motor vehicles (provide details in the table below)$ Total assets $ Details of motor vehicles
Make/Model
Colour
Year
MOJ36/05/14 Ministry of Justice Collections Unit www.justice.govt.nz/fines/civil-debt 0800 233 222
Registration number Value
PAGE 4 OF 6
5.
Provide details of any debts you are already paying
Complete this section if you are paying any debts, such as hire purchases, car payments, fines, loans (including
student loans), or credit card payments.
Debt type
Amount
still owing
Repayment
amount
Frequency
Weekly (W)
Fortnightly (F)
Monthly (M)
Lender
6. Additional information
Please write down any other information you would like the court to consider. Use extra pages if necessary.
MOJ36/05/14 Ministry of Justice Collections Unit www.justice.govt.nz/fines/civil-debt 0800 233 222
PAGE 5 OF 6
7.
Payment plan from the judgment debtor
A judge or registrar will decide how you must pay the debt. You can offer a plan for paying the debt. The judge
or registrar will consider this plan when making their decision.
Amount$ Frequency
Weekly
Fortnightly
Monthly
Lump sum
8. Date and signature
Your name SignatureDate
Select one of the following:
I am the judgment debtor
I am the judgment debtor’s lawyer
Office use only
Oath/affirmation provided
Oath/affirmation refused
Oath/affirmation not required
MOJ36/05/14 Ministry of Justice Collections Unit www.justice.govt.nz/fines/civil-debt 0800 233 222
PAGE 6 OF 6