Privacy and terms and conditions.

These General Terms and Conditions of the Dutch Thuiswinkel Organization (hereinafter: Thuiswinkel.org) have been established in consultation with the Consumers' Association in the context of the Self-Regulation Consultation Coordination Group (CZ) of the Social and Economic Council and come into force on 1 June 2014.

Table of contents:

Article   1 - Definitions

Article   2 - Identity of the entrepreneur

Article   3 - Applicability

Article   4 - The offer

Article   5 - The Agreement

Article   6 - Right of withdrawal

Article   7 - Obligations of the consumer during the reflection period

Article   8 - Exercise of the right of withdrawal by the consumer and costs thereof

Article   9 - Obligations of the entrepreneur at revocation

Article 10 - Exclusion of right of withdrawal

Article 11 - The price

Section 12 - Compliance and Additional Warranty

Article 13 - Delivery and performance

Article 14 - Duration transactions: duration, cancellation and renewal

Article 15 - Payment

Article 16 - Complaints procedure

Article 17 - Disputes

Section 18 - Industry Warranty

Article 19 - Additional or different provisions

Article 20 - Modification of the Terms and Conditions Thuiswinkel

Article 1 - Definitions

In these terms and conditions:

1. Additional agreement: an agreement whereby the consumer acquires products, digital content and/or services in connection with a distance contract and these goods, digital content and/or services by the entrepreneur or by a third party on the basis of an agreement between that third party and the entrepreneur;

2. Cooling off period: the period within which the consumer uses the product can exercise his right of withdrawal;

3. Consumer: the natural person who is not acting for purposes related to his trade, business, craft or professional activity;

4. Day: calendar day;

5. Digital content: data that is in digital form be produced and delivered;

6. Duration agreement: an agreement that extends to the regular delivery of goods, services and/or digital content during a certain period;

7. Durable data carrier: any resource - including understood e-mail - that enables the consumer or entrepreneur to receive information addressed to him personally, in a way that is future consultation or use for a period appropriate to the purpose for which the information is intended, and that unaltered reproduction of the enables stored information;

8. Right of withdrawal: the consumer's option to to waive the distance contract within the cooling-off period;

9. Entrepreneur: the natural or legal person who is a member of Thuiswinkel.org and products, (access to) digital content and/or services on offers distance to consumers;

10. Distance Agreement: an agreement concluded between the entrepreneur and consumer is concluded in the context of an organized system for the distance sale of products, digital content and/or services, with exclusive or partial use up to and including the conclusion of the agreement is made of one or more remote communication techniques;

11. Model withdrawal form: the one in Annex I of included in these terms and conditions European model form for withdrawal; Annex I does not have to be made available if the consumer is concerned order has no right of withdrawal;

12. Technique for remote communication: means that is possible be used for concluding an agreement, without the consumer and entrepreneurs need to be in the same room at the same time.

Article 2 - Identity of the entrepreneur

Entrepreneur name: Real Solutions Haarlem B.V.

Trading as name(s): TrueBase

Business address: 

A. Hofmanweg 75
2031BH Haarlem
Netherlands 

Phone number: +31889277206 

Accessibility:  van Monday to Friday from 09:00 until 17:30

Email address: customerservice@truebase.nl 

CoC number: 55022944  

VAT number: NL8515.33.413.B01     

Article 3 - Applicability

1. These terms and conditions apply to each offer from the entrepreneur and to any distance contract concluded between entrepreneur and consumer.

2. Before the distance contract is concluded, the text of these general terms and conditions made available to the consumer. If this is not reasonably possible, the entrepreneur will before the distance contract is concluded, indicate how the general conditions can be viewed at the entrepreneur and that they are requested by the consumer as soon as possible free of charge.

3. If the distance contract becomes electronic concluded, contrary to the previous paragraph and before the agreement ends distance is concluded, the text of these general terms and conditions along electronically made available to the consumer in such a way way that it can be easily stored by the consumer on a durable data carrier. If this is not reasonably possible, before the distance contract is concluded, it will be indicated where from the general terms and conditions can be read electronically and that at the request of the consumer, electronically or otherwise will be sent free of charge.

4. Just in case, in addition to these general terms and conditions specific product or service terms and conditions apply is the second and third paragraph apply mutatis mutandis and the consumer can in case always invoke the applicable provision of conflicting conditions is most favorable to him.

Article 4 - The offer

1. If an offer has a limited period of validity or subject to conditions, this is expressly stated in the offer.

2. The offer contains a complete and accurate description of the products, digital content and/or services offered. The description is sufficiently detailed to allow a good assessment of the offer made possible by the consumer. If the entrepreneur uses images, these are a true representation of the offered products, services and/or digital content. Obvious mistakes or apparent errors in the offer do not bind the entrepreneur.

3. Each offer contains such information that for the it is clear to the consumer what rights and obligations are attached to the consumer acceptance of the offer.

Article 5 - The Agreement

1. The agreement comes, subject to the provisions in paragraph 4, established at the time of acceptance by the consumer of the offer and compliance with the associated conditions.

2. If the consumer accepts the offer electronically has accepted, the entrepreneur immediately confirms by electronic means the receipt of the acceptance of the offer. As long as the receipt of this acceptance has not been confirmed by the entrepreneur, the consumer can cancel the agreement.

3. If the agreement is concluded electronically, the entrepreneur takes appropriate technical and organizational measures security of the electronic transfer of data and ensures a secure web environment. If the consumer can pay electronically, the entrepreneur to observe appropriate safety measures.

4. The entrepreneur can within legal frameworks - on the inform whether the consumer can meet his payment obligations, as well as all those facts and factors that are important for a responsible entering into the distance contract. If the entrepreneur under this research has good reasons not to enter into the agreement, he is entitled to refuse an order or request or to comply with the reasons execution to attach special conditions.

5. The entrepreneur will, no later than upon delivery of the product, the service or digital content to the consumer the following information, in writing or in such a way that it can be specified by the consumer on a can be stored in an accessible manner on a durable data carrier, include:   

   a. the visiting address of the establishment of the entrepreneur where the consumer can go with complaints;

   b. the conditions under which and the manner in which the consumer can make use of the right of withdrawal, or a clear notification regarding the exclusion of the right of withdrawal;

   c. the information about warranties and existing ones after-sales service;

   d. the price including all taxes of the product, service or digital content; where applicable, the costs of delivery; and the method of payment, delivery or performance of the distance contract;

   e. the cancellation requirements agreement if the agreement has a duration of more than one year or of is indefinite;

   f. if the consumer has a right of withdrawal has the model withdrawal form.

Article 6 – Right of withdrawal

1. The consumer can enter into an agreement with regard to the purchase of a product during a cooling-off period of 14 days without cancellation of reasons. The entrepreneur may ask the consumer about the reason for withdrawal, but not oblige him to state his reason(s).

2. The cooling-off period referred to in paragraph 1 commences on the day after the consumer, or a third party designated in advance by the consumer, who is not the carrier, has received the product, or:

   a. as the consumer in the same order has ordered several products: the day on which the consumer, or one by him designated third party has received the last product. The entrepreneur may, provided that he clearly informs the consumer about this prior to the ordering process has informed, an order of several products with a different refuse delivery time.

   b. if the delivery of a product consists of different shipments or parts: the day on which the consumer, or a by designated third party, has the last consignment or the last part receive;

   c. in the case of agreements for regular delivery of products during a certain period: the day on which the consumer, or a third party designated by him has received the first product.

For services and digital content that are not on a physical carrier has been delivered:
3. The consumer can conclude a service contract and a delivery contract of digital content that is not supplied on a tangible medium during 14 days to dissolve without giving reasons. The entrepreneur may asking the consumer about the reason for the withdrawal, but not stating it its reason(s) oblige.

4. The cooling-off period referred to in paragraph 3 starts on the day that follows the conclusion of the agreement.

Extended reflection period for products, services and digital content that has not been delivered on a tangible medium by not informing about right of withdrawal:

5. If the entrepreneur provides the consumer with the legally required information about the right of withdrawal or the model form for withdrawal provided, the cooling-off period expires twelve months after the end of the original, established in accordance with the previous paragraphs of this article reflection time.

6. If the entrepreneur referred to in the previous paragraph provided information to the consumer within twelve months of the effective date of the original cooling-off period, the cooling-off period 14 days after the day on which the consumer received.

Article 7 - Obligations of the consumer during the reflection time

1. During the cooling-off period, the consumer will act with due care with the product and packaging. He will only unpack or use to the extent necessary for the nature, characteristics and operation of to determine the product. The starting point here is that the consumer may only handle and inspect the product as he would in a shop may do.

2. The consumer is solely liable for depreciation of the product that is the result of a way of handling with the product that goes beyond what is allowed in paragraph 1.

3. The consumer is not liable for depreciation of the product if the entrepreneur does not provide it for or with it conclusion of the contract all legally required information about it right of withdrawal.

Article 8 - Exercise of the right of withdrawal by the consumer and costs thereof

1. If the consumer makes use of his right of withdrawal, he reports this within the cooling-off period by means of the model form for revocation or otherwise unequivocally to the entrepreneur.

2. As soon as possible, but within 14 days from the day following the notification referred to in paragraph 1, the consumer shall return the product, or he hands this over to (an authorized representative of) the entrepreneur. This is not necessary if the entrepreneur has offered to collect the product himself. The consumer has in any case observed the return period if he has received the product returns before the cooling-off period has expired.

3. The consumer returns the product with all delivered accessories, if reasonably possible in their original condition and packaging, and in accordance with the reasonable and clear instructions provided by the entrepreneur.

4. The risk and the burden of proof for the correct and timely exercise of the right of withdrawal lies with the consumer.

5. The consumer bears the direct costs of it returning the product. If the entrepreneur has not reported that the consumer must bear these costs or, if the entrepreneur indicates, the costs themselves the consumer does not have to bear the costs for return.

6. If the consumer revokes after first expressly have requested that the provision of service or the supply of gas, water or electricity not put up for sale in a limited volume or certain quantity starts during the cooling-off period, is the consumer owes the entrepreneur an amount that is proportional to that part of the obligation that has been fulfilled by the entrepreneur at the time of withdrawal, compared to the full fulfillment of the commitment.

7. The consumer bears no costs for the implementation of services or the supply of water, gas or electricity, which are not ready for sales are made in a limited volume or quantity, or to delivery of district heating, if:

   a. the entrepreneur the consumer the legal mandatory information about the right of withdrawal, the reimbursement of costs revocation or has not provided the model revocation form, or;

   b. the consumer does not expressly request the commencement of the performance of the service or supply of gas, water, electricity or district heating during the cooling-off period.

8. The consumer bears no costs for the full or partial supply of digital content not supplied on a tangible medium, if:

   a. he did not prior to delivery has expressly agreed to commencing compliance with the agreement before the end of the cooling-off period;

   b. he has not acknowledged his right of withdrawal to lose in granting his consent; or

   c. the entrepreneur has failed to do this consumer statement.

9. If the consumer makes use of his right of withdrawal, all additional agreements will be dissolved by operation of law.

Article 9 - Obligations of the entrepreneur in case of withdrawal

1. If the entrepreneur receives the notification of withdrawal from the enables the consumer electronically, he will send after receipt of this notification immediately an acknowledgment of receipt.

2. The entrepreneur reimburses all payments made by the consumer, including any delivery costs charged by the entrepreneur for the returned product, without delay but within 14 days following the day on which the consumer notifies him of the withdrawal. Unless the entrepreneur offers collect the product himself, he may wait with paying back until he has received it has received the product or until the consumer demonstrates that he has the product returned, whichever is earlier.

3. The entrepreneur uses the same for reimbursement means of payment that the consumer has used, unless the consumer agrees another method. The refund is free of charge for the consumer.

4. If the consumer has opted for a more expensive method of delivery than the cheapest standard delivery, the entrepreneur does not have to pay the additional costs for the more expensive method cannot be reimbursed.

Article 10 - Exclusion of right of withdrawal

The entrepreneur can offer the following products and services exclude the right of withdrawal, but only if the entrepreneur does so clearly in the offer, at least in time for the conclusion of the agreement, has mentioned:

1. Products or services whose price is subject to fluctuations in the financial market over which the entrepreneur has no influence and which may occur within the withdrawal period

2. Agreements concluded during a public auction. A public auction is understood to mean a method of sale in which products, digital content and/or services are offered by the entrepreneur to the consumer who is personally present or is given the opportunity to be personally present at the auction, under the supervision of a auctioneer, and where the successful bidder is obliged to sell the products, purchase digital content and/or services;

3. Service agreements, after full execution of the service, but only if:

   a. the execution has begun with express prior consent of the consumer; and

   b. the consumer has stated that he is loses the right of withdrawal as soon as the entrepreneur has completed the agreement performed;

4. Package travel as referred to in Article 7:500 of the Dutch Civil Code and contracts of passenger transport; 

5. Service agreements for the provision of accommodation, if in the agreement a specific date or period of implementation is provided and other than for residential purposes, goods transport, car rental services and catering;

6. Agreements relating to leisure activities, if the agreement specifies a specific date or period for its implementation provide;

7. Manufactured to consumer specifications products that are not prefabricated and that are manufactured on the basis of an individual choice or decision of the consumer, or which is clear to one specific person;

8. Products that spoil quickly or have a limited shelf life have;

9. Sealed products that for reasons of health protection or hygiene are not suitable for return and of which the seal has been broken after delivery;

10. Products that are irrevocable after delivery by their nature are mixed with other products;

11. Alcoholic drinks whose price has been agreed at the conclusion of the agreement, but the delivery of which is only possible take place after 30 days, and on which the actual value depends fluctuations in the market over which the entrepreneur has no influence;

12. Sealed audio, video recordings and computer software, of which the seal has been broken after delivery;

13. Newspapers, periodicals or magazines, with the exception of subscriptions to it;

14. The delivery of digital content other than on a material carrier, but only if:

   a. the execution has begun with express prior consent of the consumer; and

   b. the consumer has stated that he does so loses his right of withdrawal.

Article 11 - The price

1. During the period of validity stated in the offer the prices of the products and/or services offered will not be increased, subject to price changes due to changes in VAT rates.

2. Contrary to the previous paragraph, the entrepreneur may products or services whose prices are subject to fluctuations in the financial market and over which the entrepreneur has no influence, with variable offer prices. This bondage to fluctuations and the fact that any prices stated are target prices, will be stated with the offer.

3. Price increases within 3 months after the conclusion of the agreement are only permitted if they are the result of legal regulations or provisions.

4. Price increases from 3 months after the creation of the agreement are only permitted if the entrepreneur has stipulated this and:

   a. these are the result of legal regulations or provisions; or

   b. the consumer has the authority to cancel the agreement with effect from the day on which the price increase enters.

5. The ones mentioned in the offer of products or services prices include VAT.

Article 12 - Compliance with the agreement and extra guarantee

1. The entrepreneur guarantees that the products and/or services comply with the agreement, the specifications stated in the offer, to the reasonable requirements of soundness and/or usability and on the date of the arrival of the agreement existing legal provisions and/or government regulations. If agreed, the entrepreneur is also there guarantees that the product is suitable for other than normal use.

2. One by the entrepreneur, his supplier, manufacturer or importer provided additional warranty never limits the legal rights and claims that the consumer has against the consumer under the agreement entrepreneur can assert if the entrepreneur has failed in the performance of its part of the agreement.

3. An additional guarantee means any commitment of the entrepreneur, its supplier, importer or producer to which it belongs grants the consumer certain rights or claims that go beyond which it is legally obliged to do in the event that it has failed to comply with the performance of his part of the agreement.

Article 13 - Delivery and performance

1. The entrepreneur will take the greatest possible care take into account when receiving and executing orders products and in the assessment of applications for the provision of services.

2. The place of delivery is the address provided by the consumer has made known to the entrepreneur.

3. With due observance of the provisions of Article 4 of stated in these general terms and conditions, the entrepreneur will accept them execute orders expeditiously but at the latest within 30 days, unless a different delivery period has been agreed. If the delivery is delayed experience, or if an order is not or only partially possible are carried out, the consumer will receive notification of this no later than 30 days after he has placed the order. In that case, the consumer has it right to dissolve the agreement without costs and right to any compensation.

4. After dissolution in accordance with the previous paragraph, the entrepreneur refund the amount paid by the consumer without delay.

5. The risk of damage and/or loss of products rests with the entrepreneur until the moment of delivery to the consumer or a pre-designated and made known to the entrepreneur representative, unless expressly agreed otherwise.

Article 14 - Duration transactions: duration, termination and renewal

Cancellation:

1. The consumer can enter into an agreement for an indefinite period time has been entered into and which extends to the regular delivery of products (including electricity) or services, cancel at any time with observance of the agreed termination rules and a notice period of up to one month.

2. The consumer can enter into an agreement for a definite period of time has been entered into and which extends to the regular delivery of products (including electricity) or services, at any time towards the end of the fixed term with due observance of the agreed terms cancellation rules and a notice period of no more than one month.

3. The consumer can do the aforementioned in the previous paragraphs matches:

   a. cancel at any time and without limitation be terminated at a specified time or in a specified period;

   b. at least cancel in the same way as them entered into by him;

   c. always cancel with the same notice period if the entrepreneur has stipulated for himself.

Extension:

4. An agreement that has been entered into for a definite term and which extends to the regular delivery of products (including electricity understood) or services, may not be tacitly extended or renewed for a certain duration.

5. Contrary to the previous paragraph, an agreement that has been entered into for a definite period of time and which extends to the regular delivery of daily news and weeklies and magazines are tacitly renewed for a certain duration of up to three months, if the consumer extended it contract at the end of the renewal with a notice period of up to one month.

6. An agreement that has been entered into for a definite period of time and which extends to the regular delivery of products or services, is only allowed be tacitly renewed indefinitely if the consumer at all at any time with a notice period of no more than one month. The notice period is a maximum of three months in case the agreement extends to the regular, but less than once a month, delivery of daily, news and week magazines.

7. A contract of limited duration to the arranged ter delivering introductions to daily, news and weekly newspapers and magazines (trial or introductory subscription) is not tacitly continued and ends automatically after the trial or introductory period.

Duration:

8. If an agreement has a duration of more than one year after one year, the consumer may terminate the agreement at any time with a notice period of no more than one month, unless reasonableness and fairness against cancellation before the end of the agreed term reschedule.

Article 15 - Payment

1. Insofar as not otherwise stipulated in the agreement or additional conditions, the amounts owed by the consumer must be be paid within 14 days after the cooling-off period commences, or at the time of payment lack of a cooling-off period within 14 days after the conclusion of the contract agreement. In case of an agreement to provide a service, this period commences on the day after the consumer has received confirmation of the agreement.

2. When selling products to consumers, the consumer will never be obliged to pay in advance in the general terms and conditions of more than 50%. When payment in advance has been stipulated, the consumer cannot enforce any right with regard to the performance of the relevant order or service(s), before the stipulated advance payment has been made.

3. The consumer has a duty to correct inaccuracies provided or stated payment details immediately to the entrepreneur.

4. If the consumer does not arrive on time payment obligation(s), this is after it has been received by the entrepreneur pointed out the late payment and the entrepreneur gives the consumer a term of 14 days to still meet his payment obligations, after the failure to pay within this 14-day period, about it amount owed the statutory interest and the entrepreneur entitled to charge the extrajudicial collection costs incurred by him to bring. These collection costs amount to a maximum of: 15% on outstanding amounts up to € 2,500; 10% on the following € 2,500 and 5% on the next € 5,000.= with a minimum of € 40.=. The entrepreneur can benefit from the consumer deviate from the stated amounts and percentages.

Article 16 - Complaints procedure

1. The entrepreneur has a sufficiently publicized complaints procedure and handles the complaint in accordance with this complaints procedure.

2. Complaints about the implementation of the agreement must within a reasonable time after the consumer has discovered the defects, must be submitted fully and clearly described to the entrepreneur.

3. Complaints submitted to the entrepreneur will be processed within one within 14 days from the date of receipt. Like a complaint requires a foreseeable longer processing time entrepreneur within the period of 14 days with a message from receipt and an indication when the consumer can provide a more detailed answer expect.

4. A complaint about a product, service or the service of the entrepreneur can also be submitted via a complaint form on the consumer page of the Thuiswinkel.org website www.thuiswinkel.org. The The complaint will then be sent to both the entrepreneur concerned and Thuiswinkel.org sent.

5. The consumer serves the entrepreneur for at least 4 weeks time to resolve the complaint in mutual consultation. After this one period, a dispute arises that is susceptible to the dispute settlement.

Article 17 - Disputes

1. On agreements between the entrepreneur and the consumer to which these general terms and conditions apply is exclusively Dutch applicable law.

2. Disputes between the consumer and the entrepreneur about the conclusion or performance of agreements related to this entrepreneur to deliver or delivered products and services, can, with observance of the provisions below, both by the consumer and the entrepreneur be submitted to the Thuiswinkel Disputes Committee, PO Box 90600, 2509 LP in The Hague (www.sgc.nl).

3. A dispute will only be accepted by the Disputes Committee handled, if the consumer first lodges his complaint within a reasonable time presented to the entrepreneur.

4. If the complaint does not lead to a solution, it must be dispute at the latest 12 months after the date on which the file the complaint submitted by the entrepreneur, in writing or in another manner to be determined by the Commission determine form be submitted to the Disputes Committee.

5. When the consumer wants to submit a dispute to the Disputes Committee, the entrepreneur is bound by this choice. Preferably the consumer first reports this to the entrepreneur.

6. When the entrepreneur wants to submit a dispute to the Disputes Committee, the consumer will inform the consumer within five weeks of a decision to that effect entrepreneur made a written request, must express in writing or he so desires or wants the dispute to be handled by the competent authority for that purpose competent court. Does the entrepreneur not hear the consumer's choice inside the period of five weeks, then the entrepreneur is entitled to submit the dispute to the competent court. 

7. The Disputes Committee makes a decision under the conditions as laid down in the regulations of the Disputes Committee (www.degeschillencommissie.nl/over-ons/de-commissies/2404/thuiswinkel). The decisions of the Disputes Committee are made by way of binding advice.

8. The Disputes Committee will not handle a dispute or discontinue the treatment, if the entrepreneur is granted suspension of payment granted, it has become bankrupt or its business activities actually terminated before a dispute by the committee at the hearing has been dealt with and a final judgment has been rendered.

9. If, in addition to the Thuiswinkel Disputes Committee, a other recognized or with the Stichting Disputes Committees for Consumer Affairs (SGC) or the Complaints Institute for Financial Services (Kifid). Disputes Committee is competent for disputes mainly concerning the method of distance selling or service provision, the Thuiswinkel Disputes Committee preferably competent. For all other disputes, the other recognized at SGC or Kifid affiliated disputes committee.

Article 18 - Industry Guarantee

1. Thuiswinkel.org guarantees compliance with the binding advice of the Thuiswinkel Disputes Committee by its members, unless the member decides to issue the binding advice within two months of its dispatch to be submitted to the court for review. This guarantee revives, if the binding advice has been upheld after review by the court and the judgment demonstrating this has become final. Up to maximum an amount of €10,000 per binding advice, this amount will be passed on Thuiswinkel.org paid to the consumer. For amounts greater than €10,000 per binding advice, €10,000 will be paid out. For having more Thuiswinkel.org has a best efforts obligation to ensure that the member binding advice.

2. Application of this warranty requires that the consumer makes a written appeal to Thuiswinkel.org and that he transfers its claim against the entrepreneur to Thuiswinkel.org. If the claim against the entrepreneur exceeds € 10,000, becomes the consumer offered his claim insofar as it exceeds the amount of € 10,000 transfer to Thuiswinkel.org, after which this organization in its own name and costs will demand payment thereof in court in order to satisfy the consumer.

Article 19 - Additional or different provisions

Additional or deviating from these general terms and conditions provisions may not be to the detriment of the consumer and must be in writing to be recorded or in such a way that it can be used by the consumer can be stored in an accessible way in a sustainable way data carrier.

Article 20 - Amendment of the General Terms and Conditions Thuiswinkel

1. Thuiswinkel.org will not accept these general terms and conditions change in consultation with the Consumer Association.

2. Changes to these terms and conditions are only effective after they have been published in an appropriate manner, it being understood, that in case of applicable changes during the term of an offer, the for the consumer's most favorable provision will prevail.

Thuiswinkel.org

www.thuiswinkel.org

Horaplantsoen 20, 6717 LT Ede

Annex I: Model withdrawal form

Model withdrawal form

(Complete and return this form only when you have the contract)

a. To: [name of entrepreneur]

    [geographical address entrepreneur]

    [fax number entrepreneur, if available]

    [ e-mail address or electronic address of entrepreneur] 

b. I/We* share(s)* hereby inform you that I/We* our agreement concerning

    selling the following products: [product designation]*

    the supply of the following digital content: [digital content designation]*

    the provision of the following service: [designation service]*,

    revoked/revoked*

c. Ordered on*/received on* [date of order for services or receipt with products]  

d. [Consumer(s) Name]

e. [Consumer(s) address]

f. [Signature consumer(s)] (only if this form is submitted on paper)

g. [Date]

* Strike out what does not apply or fill in what of applicable.