Reference Number ______Date: ______
Initiation of a complaint to the National Debt Mediation Association in terms of the NDMA Policy
General Information
- Shaded parts of the form are for NDMA use only.
- For debt review complaints complete all sections
- For DCRS related complaints complete sections 2 and 3.
- Please send completed application form via fax to 086670 0834 or email:
1. CONSUMER DETAILS
Details of the person complaining / First Names
Surname
Identity Number / Gender
Occupation
Physical Address / Number / Street
Suburb
City
Postal Address / P.O.Box / Private Bag
Postal Code
Telephone / Code( ) / Cell number
E-mail / Business / Fax number
2. COMPLAINANT'S DETAILS
Are you complaining as a / Consumer / Debt Counsellor / Credit Provider / PDA
Other (specify)
(IF COMPLAINANT IS NOT THE CONSUMER, COMPLETE THIS SECTION)
NAME AND SURNAME:------
NAME OF ORGANISATION AND NCR NO.:------
TELEPHONE NO.:------
E-MAIL:------
FAX NO.:------
Short description of complaint and attach all relevant supporting documents:
3. DETAILS OF COMPLAINT
1. Are you complaining about a Debt Counsellor / Credit Provider / Payment Distribution Agent / Other (Please specify)
2. What is the name/s of the person/s and/or entity (business) against whom you wish to lodge a complaint?
3. What is the name, surname, reference number and contact number of the relevant parties in the above mentioned firm who attended to your matter?
4. What was the outcome of the matter?
Have you lodged a complaint regarding this with
(Please note full details if the answer to any of these questions is yes) / Any other institution or governing body / Yes / No
The National Credit Regulator / Yes / No
Any ombudsman / Yes / No
Any other institution or governing body / Yes / No
I confirm that I want the National Debt Mediation Association to consider my complaint
What do you expect the National Debt Mediation Association to do in this matter?
I understand that :
•The National Debt Mediation Association will handle my complaint according to the NDMA Standards and Procedures.
•Confidential information may be considered by the National Debt Mediation Association in the process of handling my complaint.
•The National Debt Mediation Association may need to communicate with other organizations in respect of the complaint question and may need to exchange information in this regard.
I indemnify the NDMA and/or employees or affiliates from any claim whatsoever with regards to any actions, procedures, investigations relating to this complaint or outcome. The outcome or correspondence may not be used in any way that could result in reputational disrepute of the NDMA, employees or affiliated members.
(Please note that the National Debt Mediation Association as well as the council does not have the power to order the “party/s that the complaint relates to” to reimburse you to pay any damages to you. This complaint initiates steps to resolve the matter through mediation and the procedure is aimed at resolving your dispute/complaint against the “party/s that the complaint relates to”.
The under mentioned must be completed and signed before a commissioner of oaths. If you fail to comply with this, the National Debt Mediation Association will not be able to entertain your complaint. Examples of a commissioner of oaths are an attorney, sheriff, bank manager, postmaster or police official.
------Date:------Complainant Signature
Please send completed application form via fax to: 086670 0834 or email:
Revised Complaints Initiation Form October 2011 Page 1