Financial Counsellor Authorisation Form

Financial counsellor Authorisation Form
Purpose of the Authority form

By signing this authority, you authorise the financial counselling agency to act on your behalf with the named third party, such as a creditor, debt collector, external dispute resolution scheme or a telecommunications company.

When acting on your behalf, the financial counselling agency may (amongst other things):

- seek and exchange personal information about you and your account/s;

- negotiate; and

- enter into arrangements.
Third party/Creditor :
Reference no. /Account No. If All Accounts also write All Accounts :
Full Name (#1):*
Date of birth:*

DayMonthYear
Date
Address:*
Full Name (#2):
Date of birth:

DayMonthYear
Date
Address:
Your Business details (if applicable)
Business name:
ABN
Address:
Financial counsellor’s name:
FC Registration number:
FC Email:
admin@moneymentors.org.au
Name (#1)::*

Clear
Date:*

DayMonthYear
Date
Name (#2)::

Clear
Date:

DayMonthYear
Date
This form was developed by Financial Counselling Australia in consultation with industry, peak bodies and EDR schemes | April 2020
Should be Empty:

Financial counsellor Authorisation Form