(YOUR INFORMAL DEBT DISTRIBUTION SOLUTION) Client Surname & Initial(s) Client s Code Stop order Date DOCUMENTS TO BE ATTACHED TO THIS APPLICATION

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1 1 PROPOSAL FOR A PAYMENT PLAN IN TERMS OF SEC129 (1) (a) and Sec 130 OF THE NATIONAL CREDIT ACT (ACT 34 OF 2005) AND APPLICATION FOR ALTERNATIVE DEBT RESOLUTION OPTION (YOUR INFORMAL DEBT DISTRIBUTION SOLUTION) Client Surname & Initial(s) Client s Code Stop order Date DOCUMENTS TO BE ATTACHED TO THIS APPLICATION ID: Copy of ID document FICA: Payslip: Bank Statement: Creditors: New Bank Account: Lawyers letters and summons: Copy of a utility or bank statement, an account or any document showing your residential address. (Not older than 3 Months Copy of payslip/pay sheet Latest bank statement All Creditor s account details This program cannot commence until your new bank account details is supplied to Eagle Mediation and Solutions Please note that, should you have been summonsed to appear in Court, you will have to appear, as this process does not stop any court appearances and processes Representatives Name Phone No

2 2 APPLICANT DETAILS Title: ID No: Surname: Full names: Phone No: Cell No: Postal & Residential address: Code: Marital status: Dependants: Home owner (Y/N): Market value: Bond balance: Institution: SPOUSE DETAILS Surname: First name: ID No: Employer: Gross Income: Nett Income: EMPLOYMENT DETAILS Employer/Company name: Address: Code: Date started: Work Tel No: Employee No: HR Tel number: Pay Date Are you currently under debt review or administration Yes No Client: Witness/Consultant:

3 3 No Expenses Amount No Expenses Amount 1 Car Installment Sub Total Monthly Expenses 2 Fuel 18 Membership 3 Vehicle Maintenance 19 Subscriptions 4 Train & Bus Pass. 20 Dining out 5 Bond Repayment 21 Events & Movies 6 Rent 22 Music & Hobbies 7 Residence Maintenance 23 Vacation 8 Insurance on House 24 Dry Cleaning 9 Groceries 25 New Clothes 10 Municipal Taxes 26 Donations 11 Phone, Home & Cellphone 27 Child Care 12 DSTV 28 Tuition, College 13 SABC 29 Pocket Money 14 Electricity, Water, Gas 30 Gifts 15 Internet 31 Other 16 Medical 32 Other 17 Life insurance 33 Other Sub Total Monthly Expenses Total Monthly Expenses Income Nett Salary Self Nett Salary Partner Other Income Other Income Nett Disposable Income I hereby confirm that all of the above is a true reflection of my financial position. Signed at: on 20 Client: Witness/Consultant:

4 4 CREDITORS LISTING FORM Creditor Reference Number Outstanding Balance Monthly Instalment TOTAL I hereby confirm that all of the above is a true reflection of my financial position. If you list a credit card please make sure your budget account is listed as well. Signed at: on 20 Client: Witness/Consultant:

5 5 SPECIAL POWER OF ATTORNEY I, the undersigned ID number Address Do hereby acknowledge that my personal financial situation is of such a nature that I am currently unable to meet my present and future monthly commitments 1. I am unable to meet my current monthly commitments to creditors. I foresee that the situation will continue for a period of longer than six (6) months from this date. The distribution program, the debt mediation process and proposal of the payment plan to creditors have been fully explained to me and is acceptable and may, if implemented, drastically improve my present financial positions with the ultimate goal of having me financially rehabilitated and debt free. 2. I hereby instruct, Eagle Mediation and Solutions, Von Ludwig Attorneys and their nominee to take whatever legal steps they may deem necessary to ease or improve my financial position, as well as to improve my ability to meet my current financial liabilities, either in full or in part towards my creditors and to propose a payment plan to my creditors as is contemplated in Sec 129(1) (a) and Sec 130 of the National Credit Act. 3. Eagle Meditation and/or the Attorney shall have the following powers, for the purpose mentioned above; To obtain and disclose all information regarding my financial position to the creditors; To negotiate a reduced or delayed monthly instalments with my creditors; To cancel any authority given by me to my creditors prior to this agreement that may be necessary to improve my financial position; To propose a payment plan to my creditors as is contemplated in Section 129 (1) (a) and Sec 130 of the National Credit Act. To deduct all monies necessary from my nominated bank account and to distribute it to my creditors on a monthly basis; Not to act in contravention with any South African legislation; Not to conclude any agreements with creditors that may unfairly prejudice my rights as debtor. 4. I hereby direct and consent to Eagle Mediation and Solutions and/or the Attorney to request and receive my credit information ( credit report ) from any registered credit bureau and consent to the release of the credit information by the credit bureau. 5. Eagle Mediation and Solutions and/or the Attorney may also obtain and utilise credit bureau record and information as required for credit, risk and affordability assessment, as well as tracing purposes and any other purposes contemplated by the National Credit Act Eagle Mediation and Solutions and/or the Attorney may report or release any such information to another person to the extent permitted or required by the Act, other national legislation or provincial legislation, or an order of the court or the national consumer tribunal established by the National Credit Act provided that it is related to and limited to the purpose of debt mediation.

6 6 7. That the service/s to be rendered by Eagle Mediation and Solutions and/or the Attorney on my behalf are clearly understood by me and I acknowledge that neither Eagle Mediation and Solutions, nor The Attorney will make any payments on my behalf of any amounts owed to any of my creditors, save for such monies, which I have paid to them to settle outstanding debts owed. 8. Furthermore: I. I acknowledge that the above process is subject to the acceptance by my creditors: II. I acknowledge that I have been informed that my creditors may decide to reject the repayment plan and take legal action against me to protect their own interests. Should this however happen I confirm that I will not hold Eagle Mediation and Solutions and/or the Attorney responsible or liable for any damage which I may suffer as a result thereof. III. I acknowledge that I have been informed that the payment period of my debt through this program will be extended over a longer period of time, that interest will accrue on the outstanding amount as was agreed with the credit provider and I also acknowledge that at this point in time this option is the only way in which I can alleviate and improve my present financial position, with the ultimate goal of having me financially rehabilitated and debt free. IV. I indemnify all employees and nominees of Eagle Mediation and Solutions and Solutions and/ or the Attorney against any claim that may be instituted against them, arising from any act or omission by any such person appointed by Eagle Mediation and Solutions and Solutions and/ or the Attorney or its nominee in the lawful execution of the terms of this Power of Attorney entered into with myself, and confirm that Eagle Mediation and Solutions and/ or the Attorney shall not be liable for any damages suffered by me resulting from any act or omission of whatsoever nature, however arising. V. In the event of me not punctually paying any amount to Eagle Mediation and Solutions and/ or the Attorney, as contained herein, Eagle Mediation and Solutions and/ or the Attorney shall be entitled to, with 7 days prior notice to me, terminate this mandate and decline to further act for me, which will have the result that my creditors may collect amounts due to them as they may deem fit. VI. I hereby acknowledge that all lawful actions taken by Eagle Mediation and Solutions and/ or the Attorney under this Power of Attorney are tacitly agreed by me, that I ratify same and I will be bound to such agreements as principal debtor. I declare that: The information in this document is true and correct. That I have read the terms and conditions of this agreement, that the contents were explained to me and that I understand them. Signed at: on 20 Client: Witness/Consultant:

7 7 HOW DOES THE PROGRAM WORK? PLEASE NOTE THAT YOU WILL NOT BE PLACED UNDER ADMINISTRATION OR UNDER DEBT REVIEW OR COUNSELLING, BUT ON A INFORMAL DISTRIBUTION PROGRAM WHICH WILL BE NEGOTIATED ON YOUR BEHALF WITH ALL YOUR CREDITORS BY EAGLE MEDIATION AND SOLUTIONS AND THE ATTORNEYS. 1. Eagle Mediation and Solutions will negotiate on your behalf with the various creditors (cannot assist with bonds, motor vehicle finance, garnish orders, maintenance and traffic fines). All other accounts are negotiable. 2. They will negotiate a better instalment to make it more affordable for you and therefore improve your NETT disposable monthly income and will in terms of Section 129 (1) (a) and Sec 130 of the NCA propose a payment plan to the creditors. 3. Once your application has been processed a consent to mediate will be issued which you must sign and return to Eagle Mediation and Solutions. You will then receive a letter confirming that you are under mediation. 4. The Consent to Mediate serves as our formal quote. 5. On signing the consent an Eagle Mediation and Solutions account will be opened for you in your name. Your monthly mediated payment will be paid into your Eagle Mediation and Solutions account from where it will be allocated and disbursed to your various creditors. How to make a deposit: Account Name: Eagle Solutions Bank: Standard Bank, Branch Code: Account Number: Reference number: To be allocated on your consent to mediate. 6. Distribution statements will be available on request and as from 2013 you will gain access to your mediation account via your cellphone, and or via internet, thus enabling you to verify the payments made on your behalf. 7. No upfront cash fee or payment is required or allowed to be charged by any agent. 8. PLEASE NOTE that should you have debit orders on your bank statement it is your responsibility to have them removed and or stopped and to inform the bank regarding the program you are about to enter. 9. It is imperative that you close the bank account where your salary is currently deposited into as all your current debit orders will still be deducted from your current bank account, notwithstanding the fact that alternative arrangements have been made with your creditors. 10. Also if you have had a Warrant of Attachment on your furniture from a furniture store, you have to inform the store regarding your program you are about to enter as they might proceed to collect your furniture and other assets acquired under asset finance. 11. Please note that this is an Informal Distribution program and you might already be blacklisted as you are in arrears with your account. 12. A 5% fee will be charged on the mediated distribution amount to keep you as our client, to negotiate and communicate with the creditors on your behalf throughout the period that you are under mediation with Eagle Mediation and Solutions. A further 5% will be charged to collect the monthly debit order, process the payments and do the monthly distribution to your various creditors and to cover all and any banking costs on your mediation account. 13. PLEASE NOTE that the first instalment will be held back to cover all documentation completion, mediation and other initial fees. Your creditors will be paid from the 2 nd month. 14. Should you want to withdraw from the process once the Consent to Mediate was signed your first payment will be used as a cancelation fee. I undertake to not incur any further debt or make use of any available revolving credit while I am under debt mediation. Signed at: on 20 Client: Witness/Consultant: