Mandate to collect receivables

Please fill in the following form, print it out, sign it and send it together with copies of orders, invoices, etc. by mail or fax to

Rechtsanwälte von Moers
Nidegger Str. 21
50931 Köln
Fax: +49 (0)221 / 75 95 931

The fields marked * are mandatory.
The [?] contains help text for certain terms.

Information about you

Your capacity:*

Your company

Company (as per register):
Legal form:

Power of representation / your personal data

Authorised representative: [?]
In the case of an individually-owned firm or an individual, please indicate this person.

In all other cases, please indicate the body authorised to represent.

Please indicate the chairman of the board in the case of a public limited company.

In the case of a GmbH & Co. KG, please refer to the GmbH acting as general partner and indicate its managing director
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Form of address:*

Mrs.

Mr.

Last name:*
First name:*

Your contact data

Street:*
Building number:*
Postal code:*
Place:*
Telephone:*
Fax:*
E-Mail:*
Entitlement to deduct input tax:* [?]
If you are entitled to deduct input tax, the VAT amount we charge in our invoices is not a disadvantage to you. In this case, your debtor shall not be obliged to reimburse this VAT amount, since you will be able to offset the amount against your sales tax amounts.

In cases of doubt, please contact your local tax office.
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Yes

No

Information about your debtor

Capacity of your debtor:*

Company of your debtor

Company (as per register):
al form:
Registration court:
Register number:

Power of representation / personal data of the debtor

Authorised representative: [?]
In the case of an individually-owned firm or an individual, please indicate this person.

In all other cases, please indicate the body authorised to represent.

Please indicate the chairman of the board in the case of a public limited company.

In the case of a GmbH & Co. KG, please refer to the GmbH acting as general partner and indicate its managing director
close
Form of address: *

Mrs.

Mr.

Last name:*
First name:*

Contact data of your debtor

Street:*
Building number:*
Postal code:*
Place:*
Country:*
Telephone:*
Fax:*

Information about your receivables

1. Claims on the debtor mentioned above

Invoice date:*
Invoice number:*
Reason for the claim:* [?]
Please indicate here what your claim is based on (e. g. sales contract, rental agreement, damages). A short description will help us in relation to the order for payment procedure to assign your claim to the correct number in the official catalogue of principal claims.
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Amount of principal claim (gross):* [?] [?]
Please note that the total amount of all claims indicated by you must be between € 5,000.00 and € 3,000,000.00.
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Maturity:*
Costs incurred so far: [?] [?]
Please indicate here the costs of debt collection incurred up to the time you have engaged us. This includes e. g. dunning costs, inquiries, bank return fees, postage charges, etc.
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Payment(s) made:* [?] [?]
Please indicate here when and how much the debtor has paid towards this claim. This is important for the calculation of default interest.
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2. Claims on the debtor mentioned above

Invoice date:*
Invoice number:*
Reason for the claim:* [?]
Please indicate here what your claim is based on (e. g. sales contract, rental agreement, damages). A short description will help us in relation to the order for payment procedure to assign your claim to the correct number in the official catalogue of principal claims.
close
Amount of principal claim (gross):* [?]
Please note that the total amount of all claims indicated by you must be between € 5,000.00 and € 3,000,000.00.
close
Maturity:*
Costs incurred so far: [?]
Please indicate here the costs of debt collection incurred up to the time you have engaged us. This includes e. g. dunning costs, inquiries, bank return fees, postage charges, etc.
close
Payment(s) made:* [?]
Please indicate here when and how much the debtor has paid towards this claim. This is important for the calculation of default interest.
close

3. Claims on the debtor mentioned above

Invoice date:*
Invoice number:*
Reason for the claim:* [?]
Please indicate here what your claim is based on (e. g. sales contract, rental agreement, damages). A short description will help us in relation to the order for payment procedure to assign your claim to the correct number in the official catalogue of principal claims.
close
Amount of principal claim (gross):* [?]
Please note that the total amount of all claims indicated by you must be between € 5,000.00 and € 3,000,000.00.
close
Maturity:*
Payment(s) made:* [?]
Please indicate here when and how much the debtor has paid towards this claim. This is important for the calculation of default interest.
close

Remark(s):

Enclosures:*

Mandate


I/We hereby authorise the Lawyers von Moers to collect the claim(s) indicated in this form. The Lawyers von Moers will promptly send me/us a detailed statement of costs. The mandate shall be deemed to be binding only after confirmation of the costs. In addition, court fees and costs of execution will accrue. I/We confirm that I/we have taken note of the complete Standard Terms of Engagement and the Conditions for the Collection for Receivables which apply to this mandate. With the order's consignment I comply with the storage of my personal data for the purpose of the mandate's processing. The lawyers von Moers are not allowed to make any ulterior use of my data due to their obligation of confidentiality, hence it will not occur.

I/We also request the Lawyers von Moers to obtain the following information about the debtor indicated in this form. For doing so, another € 25.00 plus VAT (€ 29.00 gross) will be charged for debtors resident in Germany, and another € 75.00 plus VAT (€ 87.00 gross) will be charged for debtors resident abroad.

Extract from the Commercial Register:

Information from Creditreform:

Information from the directory of insolvent debtors (Germany):

Right of revocation

Unless the claim is based on your commercial or self-employed business activities, you may revoke your contractual statement within two weeks in writing (e. g. letter, fax, email) without giving any reasons. The time limit starts at the earliest upon receipt of this instruction. The timely dispatch of the request for revocation shall suffice to comply with the time limit. The request for revocation shall be sent to the contact details above or by email to info@vonmoers.de.

Consequences of revocation

In the case of effective revocation, the services rendered on both sides shall be returned and the advantages derived, if any (e. g. interest), shall be surrendered. We shall be entitled to compensation for lost value if you cannot return to us the performance received, or can do so only in part, or only in deteriorated condition. Obligations to reimburse payments must be fulfilled by you within 30 days after dispatch of your declaration of revocation.

 

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Ort, Datum				Unterschrift