TO:......................................................... |
(name of debt settlement service merchant) |
........................................................... |
........................................................... |
(address of debt settlement service merchant) |
Telephone number of debt settlement service merchant, where applicable: |
(......) ..................... |
Where applicable, technological address of debt settlement service merchant: ........................................ |
DATE: ........................ (date on which form is sent) |
Under section 214.17 of the Consumer Protection Act, I hereby cancel the contract No. ......... (contract number, if any) entered into on ........... (date on which contract is entered into) at: |
....................................................................................... |
........................................................................................ |
(place where contract is entered into) |
.............................................. |
(name of consumer) |
...................................................................................... |
(signature of consumer) |