Creditor Employee                               Debtor Employer

T.R. Identity No.:                                  Name Surname/Title:

Name Surname:                                   Workplace Address/Phone:

Father’s Name:                                    Workplace SSI No.:

SSI No:                                                 Workplace Tax Office:

Birthplace:                                           Workplace Tax No:

Birthdate:

Residential Addres/Phone:

The way in which the debt follow-up is carried out:

• Obtaining a certificate of insolvency
• Concordat declaration
• Bankruptcy
• Postponement of bankruptcy

Basic wage receivables by month

YEAR ……….

January:

February:

March:

April:

May:

June:

July:

August:

September:

October:

November:

December:

                                                                       APPROVED BY

Employee:                                                       Name Surname/Title:

Signature:                                                       Approval Date:

                                                                       Address:

                                                                       Signature         Seal      Seal