APPLICATION FORM

and

I hereby confirm that these are the only outstanding creditors for my Debt Review application.

Supporting Documents

I understand that in terms of Section 86 of the National Credit Act no.34 of 2005, the following documents must be submitted to ensure that my debt review program will be successful. A copy of my South African ID/Passport must be uploaded by selecting the document from your device and clicking on the upload button.

Please note the following:

The National Credit Act prohibits any person who is not registered as a Debt Counsellor to do the following: • To engage in the services of a debt counsellor and hold them out to consumers as being authorised to offer such a service. • To make a determination that a consumer is over-indebted • To re-arrange a consumer’s debt obligations Please note that Prime Debt Solution employs a number of registered debt counsellors and administrative staff. Any or/all advise, and calculations is the function of a registered debt counsellor and support staff may only assist with typical examples of such calculations. Final calculations and recommendations will be attended to by a registered debt counsellor.

I/we understand that if my/our application for debt review is successful, my/our debt counsellor will have to approach the Court for a Court Order and serve a copy of the application on me/us. I/we consent to service of said application by way of the email address below.

Terms & Conditions

In order to finalise your Prime Debt Solution application each section of the Terms & Conditions (Sections A, B & C) must be accepted & signed.
1. Therefore I/we,

and

do hereby acknowledge that my personal financial situation is of such a nature that I am currently unable to meet my present monthly commitments to my credit providers or foresee it to be the case in the near future.

2. I undertake to comply with all requests from the Debt Counsellor to assist him/her to evaluate my state of indebtedness and the prospects for responsible debt restructuring.

3. The determination of my debt position and the debt-restructuring plan by a debt counsellor has been fully explained to me and is acceptable and may, if implemented, drastically improve my present financial position.

4. I hereby instruct Prime Debt Solution to take whatever legal steps they may deem necessary to ease or improve my financial position, as well as to improve my inability to meet my current financial liabilities, either in full or in part, towards my credit providers.

5. I hereby grant Prime Debt Solution the following powers and authority:

a. To correspond and communicate and append my name in such

correspondence with all my credit providers, credit bureau or financial services providers.

b. To obtain and disclose all information regarding my financial position to/from credit providers and credit bureaus. I hereby authorize Prime Debt Solution to verify my personal credentials and financial records. I furthermore unconditionally indemnify Prime Debt Solution and its varication suppliers against any liability that may result from furnishing information in this regard.

c. To recommend and negotiate a debt-restructuring plan with my credit providers,

d. To cancel any authority given by me to my credit providers prior to this agreement that may be necessary to improve my financial position,

e. To investigate potential Reckless Lending with the intention of obtaining a declaration of Reckless Lending. Should I not require such an investigation, I shall provide written notice to Prime Debt Solution. In the event that I do not request the investigation, the fee referred to in paragraph 8(b)(ii) will not be due or payable unless I later instruct otherwise, in which case it will become due and payable on the date of such instruction.

f. To instruct an attorney to apply to the magistrate’s court for an order recording the debt-restructuring plan or recommendation. g. To obtain a Credit Life Insurance quotation, as required under Section 106(6) of the NCA, for credit agreements where such insurance is necessary. I grant Prime Debt Solution the authority to act on my behalf in deciding whether to accept or reject the quotation, without my direct involvement, if it is in my favour. Prime Debt Solution may implement the policy without requiring further approval from me.

6. I, the undersigned authorise Prime Debt Solution to obtain my complete credit profile from Transunion, Experian, XDS or any other credit bureau registered with the NCR. I also authorise Prime Debt Solution to store my credit record and account information on their system for as long as it may be required, in order to enable Prime Debt Solution to perform the functions as envisioned in terms of Section 86 of the NCA.

7. That the services to be rendered by Prime Debt Solution on my behalf are clearly understood by me and I acknowledge that Prime Debt Solution does not undertake to make payment on my behalf of any amount to any of my credit providers.

8. I agree to pay Prime Debt Solution the fees as explained to me, and which are calculated as follows:

a. An Application and Administration fee of R 350.00 plus Valued Added Tax.

b. A Determination fee-

(i) A restructuring fee in the amount equal to the amount established as the rehabilitation amount on day 35 of the process, and accepts that an upward adjustment may be made to the rehabilitation amount in the application form (Form 16), as on the date of application, or R 8000.00 (For a single application) and R 9000.00 (For consumers married in community of property or joint application) plus Valued Added Tax, whichever amount is the lesser, The fees in (a) and (b)(i) shall be payable in the first month of my application.

(ii) A Reckless Lending Assessment fee of R 1 500.00 plus Valued Added Tax, payable in the second month of my application.

c. An After-Care fee of 5% of my payment – to a maximum of R 450.00 per month plus Valued Added Tax; payable monthly for the duration of my debt review,

d. A Payment Distribution Agency (PDA) fee of 3% of the monthly payment, with a minimum of R 50.00 up to a maximum of R 500.00 plus Valued Added Tax; payable for the duration of my debt review.

e. An Attorney Fee / Legal fee to obtain a court order, Prime Debt Solution must appoint attorneys. The fee is payable to Prime Debt Solution or its nominees to enable the debt counsellor to full his/her duties in this regard and the terms will be agreed upon in writing between Prime Debt Solution/its nominees and the consumer, payable in the second and succeeding months of my application.

f. All fees will be included in the restructuring

9. I acknowledge that if I inform Prime Debt Solution, after a court order has been obtained for my debt review, of a creditor that was not previously disclosed by myself and I want that particular creditor to be included in the debt re-arrangement plan, the whole process will have to start over and all above fees will be payable as if I was never placed under debt review.

10. I am aware that I may not incur any further debt whilst I am under debt review or until Prime Debt Solution has issued a clearance certificate stating that I have fulfilled all of my payment obligations in terms of my debt-restructuring plan or court order.

11. I indemnify all employees and nominees of Prime Debt Solution against any claim that may be instituted against it arising from any act or omission by such person appointed by Prime Debt Solution or its nominee in the lawful execution of the terms and conditions of this agreement/power of attorney entered into with myself, and confirm that Prime Debt Solution all not be liable for any damages suffered by me resulting from any act or omission of whatsoever nature, however arising.

12. In the event of me not punctually paying any of my monthly payments to the Payment Distribution Agent in terms of my debt restructuring plan Prime Debt Solution shall be entitled to terminate this agreement and decline to further attend to my case, which will have the result that my credit providers will collect all amounts due to them as they deem fit.

13. All confidential information received by Prime Debt Solution will be treated as such.

14. I hereby confirm that the critical aspects of the Debt Review process have been fully explained and that I have been informed of the following by the Prime Debt Solution Facilitator:

- I agree to the below:

I must go to the bank and stop all debit order-payments to creditors. I take full responsibility for this step.

I must open a new savings account at an institution where I don’t have any credit obligations.

I take full responsibility for any amounts deducted from my old accounts if I neglected to open a new account according to Prime Debt Solution instructions.

I must arrange with my salary department to deposit my salary into my new bank account.

I must stop all creditor related deductions from my salary immediately. This excludes court orders. Prime Debt Solution will not be able to assist with this. 15. I declare that:

a. The information in this document is true and correct:

b. That I have read and understood the terms and conditions of this agreement/power of attorney, and that the contents have been explained to me.

16. I acknowledge that Prime Debt Solution to act as the administrator of the debt review process. I explicitly acknowledge that Prime Debt Solution and its employees shall have the same rights and indemnifications as contained in this Agreement and Power of Attorney, and I hereby ratify or promise to ratify the mandate, and all that Prime Debt Solution does on my behalf as if done by myself.

17. I confirm that I am currently residing at the address mentioned in my application form and will immediately inform Prime Debt Solution in writing of any change of address. I accept that a new Legal Administration Fee will be payable to apply for a court date in a new jurisdiction if I fail to adhere to this request.

18. I acknowledge that: Prime Debt Solution and or its employees shall in the execution of their duties obtain personal data (as contemplated in the Protection of Personal Information Act (POPIA) of the consumer,

I authorise Prime Debt Solution and or its employees to:

a. obtain such personal data as may be legally required,

b. utilise the said data in the execution of its / their statutory duty,

c. disclose the said data to its / their attorneys to make application to court,

d. safe keep and store the said data for the prescribed statutory period, as contemplated in the National Credit Act, 34 of 2005, as amended.

The Consumer ratifies and shall ratify all that was legally done by Prime Debt Solution and or its employees in the exercise of their statutory duty.

The Consumer indemnifies Prime Debt Solution and or its employees and or its attorneys against any direct and or consequential losses that the Consumer may sustain as a result of a third party, not associated to Prime Debt Solution and or its employees, releasing or disclosing any information and or data.

Section B - Agreement in Respect of Legal Fees

I/we agree to pay Prime Legal Partners (Pty) Ltd the legal fees as explained to me, and which are calculated as follow:

1. In order to obtain a court order Prime Debt Solution or its nominees must appoint attorneys. The matter might become opposed at Court and might be referred to trial. A fixed legal administration fee of R 8,800.00 (Vat Excluded) must be paid to enable Prime Debt Solution or its nominees to appoint attorneys and to attend to all aspects concerning the required court case pertaining to the re-arrangement of my obligations in terms of the National Credit Act. This fee will remain fixed irrespective of the number of creditors opposing the application, the number of court appearances necessary to obtain the order and to what extent the debt counsellor must assist the court with testimony, further proposals, etc. The legal administration fee included the costs of an attorney attending to the negotiation of a male fide termination and/or legal steps of a creditor. Prime Debt Solution or its nominees will at its own costs make available its attorneys to consult with the consumer(s) in this regard. This fee does not include the actual costs of the defence of the summons, if necessary. In the event that you withdraw from the application and or fail to cooperate and the debt counsellor suspends his further services, the legal fees or any remaining portion thereof shall be kept on your file and be applied for any future legal process in which your debt counsellor may be called upon to intervene, testify and or to resolve a dispute as your debt counsellor remains the debt counsellor of record notwithstanding your withdrawal or suspension. In the event that you request a transfer to another debt counsellor of your choice, the legal fees or remaining portion thereof shall be paid to the newly appointed debt counsellor.

2. If in the opinion of Prime Debt Solution or its nominees the Magistrate’s Court application for re-arrangement is unsuccessful and the ruling is unfair towards the consumer(s), Prime Debt Solution or its nominees will proceed to appeal the matter to a higher court. The legal administration fee also includes the costs hereof. Prime Debt Solution or its nominees will have full discretion in deciding whether the matter should be taken on appeal or not.

3. In the event that a creditor in our opinion, refuses to participate and negotiate in good faith in the debt review process, as required by the NCA, and it becomes necessary for the consumer to enforce his/ her rights in terms of sections 86(11) and 85 of the NCA, Prime Debt Solution or its nominees undertakes to instructs its attorneys to draft the required supporting documentation so as to support the consumer’s application. The cost hereof is included in the aforesaid fee.

4. Prime Debt Solution or its nominees will not be able to provide the service and refer the matter to court failing payment of this fee.

5. I acknowledge that the fees referred to above will be deducted from my monthly payment made to the Payment Distribution Agency appointed to collect and distribute my monthly payments in terms of my debt restructuring plan and will be paid directly by the Payment Distribution Agent to Prime Debt Solution or its nominees.

6. All fees will be included in the restructuring process.

hereby appoint and mandate Prime Debt Solution (Pty) Ltd to act on my behalf with regards to all insurance and related administration matters in respect of my existing and new credit protection covers.

I confirm that Prime Debt Solution shall be acting on my behalf and in my interest. The Policy recommended by Prime Debt Solution is the INFUSSION CREDIT LIFE PLAN

As I am over-indebted and need more affordable insurance, I hereby request that all existing credit insurance held by me be cancelled, where premium is affordable and/or where they provide more comprehensive cover and benefits, and that such existing credit insurance be replaced with an appropriate policy recommended by Prime Debt Solution.

I confirm my understanding that:

• The Policy, recommended by Prime Debt Solution, is the INFUSSION CREDIT LIFE PLAN, underwritten by AFRICAN UNITY LIFE (Pty) Ltd, and who’s Compliance Officer can be contacted at 086 123 4555. The underwriting manager of the policy is Infussion Financial Services (Pty) Ltd.

I know and understand that I have a 31-day cooling off period during which I can cancel this policy, understanding that I cannot cancel any credit insurance that was part of my original credit agreement with any Creditor.

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NB: Electronic Signature: Please be advised that by clicking on any “SUBMIT” button on this site, you will SUBMIT an electronic SIGNATURE as contemplated in SECTION 11 of the Electronic Communications and Transactions ACT, NO.25 of 2002.

Such signature carries with it all the weight of all contractual and legal obligations which may arise from the submission of such signature.

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