FeePay Disbursement Funding Application

Funding Details

Firm Name *

Firm Contact *

Contact phone *

Term of Funding *

Disbursement Fees *

Matter Details

Client/Matter Code

Description of Matter *

Personal Injury Matter Yes No *

FeePay Disbursement Funding Application

Applicant Details

Title

Applicants Full Name *

Date of Birth *

Gender *

Residential Address *

Telephone contact *

Email address

Aust Citizen / Resident? Yes No *

Number of dependants *

Marital Status *

Employment Status *

Residential Status *

Employment Details

Length of time employed Employers business name Employers phone #

Boarding Details

Time at current address Property owners name Property owners phone

Rental Details

Time at current address Real estate agents name Real estate agents phone

Mortgagor Details

Time at current address Bank / Mortgagors name Balance of mortgage

FeePay Disbursement Funding Application

Application Type

Please select the application type and note that co-applicants must reside with the applicant Single Applicant Joint Applicants *

Co-Applicant Details

Relationship to Applicant

Title

Full Name

Gender

Date of Birth

Aust Citizen / Resident? Yes No

Net Monthly Income Details

Income from Employment

Income from Investments

Income form Centrelink

Income from other source

please provide details of OTHER income

Total *

Monthly Expense Details

Mthly Mortgage/Rent

Household Expenses

Credit Card/Loan Repayments

Other Expenses

please provide details of OTHER expenses

Totalexp *

Privacy Release

You give your authorisation to FeePay Funding Pty Ltd and Evergreen Finance Company to seek information about your credit standing and history. You also agree that Evergreen Finance Company may obtain confirmation of your income, employment and residential information, which may be used for the purpose of assessing your application for credit. Evergreen Finance Company reserve the right to confirm and verify any of the information given on this application.

I ACCEPT [I intend that a check on this button to be my signature and by clicking I agree to the above statement and its terms and I/we warrant that the information provided to EFC, including these financial details, is correct in all respects and I/we do not see any foreseeable changes in the information provided.] *

Please enter the verification code below

Thank you for submitting your Disbursement FeePay Application form.

Your application will be processed within 24 hours and approval advice will be emailed to the firm within 2 business days.

FeePay Funding is the leading provider of cash flow friendly fee funding and payment plan facilities for service providers.

FeePay implements and manages the payment facility with your clients directly, taking the hassle out of debtor management whilst allowing your clients the flexibility of a payment plan.

FeePay Disbursement Funding Application

FeePay Disbursement Funding Application

FeePay Disbursement Funding Application

Privacy Release

Thank you for submitting your Disbursement FeePay Application form.

Your application will be processed within 24 hours and approval advice will be emailed to the firm within 2 business days.