Date: ............................................................................ |
(date on which contract is entered into) |
Place: ............................................................................. |
(place where contract is entered into) |
.................................................................................... |
(name of merchant) |
.................................................................................... |
.................................................................................... |
(address of merchant) |
.................................................................................... |
.................................................................................... |
(telephone number of merchant) |
.................................................................................... |
(where applicable, technological address of merchant) |
.................................................................................... |
(merchant’s permit number) |
.................................................................................... |
(name of consumer) |
.................................................................................... |
.................................................................................... |
(address of consumer) |
1. Detailed description of each of the goods and services to be provided under the contract ..................................................................................................................................... ..................................................................................................................................... ..................................................................................................................................... | |
2. Scheduled dates for the performance of the merchant’s obligations ...................................................................................................................................... ...................................................................................................................................... | |
3. Charges and fees that the consumer may be required to pay IF ALL the propositions are ACCEPTED by the creditors $.......... | |
4. List of creditors disclosed by the consumer and the amount and description, including the credit rate, of each of their claims ..................................................................................................................................... ..................................................................................................................................... ..................................................................................................................................... | |
5. Total amount owed to creditors by the consumer $.............. | |
6. Proposal the merchant undertakes to make to each of the consumer’s creditors, including the terms and conditions of payment proposed for each debt ..................................................................................................................................... ..................................................................................................................................... ..................................................................................................................................... ..................................................................................................................................... ..................................................................................................................................... ..................................................................................................................................... | |
7. The amount of any payment to be made to the merchant by the consumer for remittance to the creditors, and the frequency and dates of the payments ..................................................................................................................................... ..................................................................................................................................... ..................................................................................................................................... | |
8. The merchant will receive or attempt to receive amounts from a creditor as consideration for entering into the contract (one of the boxes below must be checked) | |
⃞ Yes ⃞ No | |
9. If applicable, a description of the goods received in payment, as a trade-in or no account, their quantity, and the priced agreed on for each of them ..................................................................................................................................... ..................................................................................................................................... | |
10. The term and expiry date of the contract | |
11. The consumer may resolve the contract at the consumer’s sole discretion within 10 days after that on which each of the parties is in possession of a copy of the contract. |