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 toRechtsanwälte 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 company
Power of representation / your personal data
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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Mrs.
Mr.
Your contact data
In cases of doubt, please contact your local tax office.
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Yes
No
Information about your debtor
Company of your debtor
Power of representation / personal data of the debtor
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
Mrs.
Mr.
Contact data of your debtor
Information about your receivables
1. Claims on the debtor mentioned above
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2. Claims on the debtor mentioned above
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3. Claims on the debtor mentioned above
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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.
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