ACKNOWLEDGEMENT OF DEBT AND UNDERTAKING

GIVEN BY

JOSE SY
ID NO.: __________________________

AND

_____________________
ID NO.: __________________________

TO

MIKE TAN
ID NO:
(hereinafter referred to as "the Creditor")

We, the undersigned, ____________________ and ____________________ with address at

________________________________________ which address I choose as domicilium citandi et
executandi for purposes hereof

do hereby admit that we are liable, and hold ourselves bound to

STEENKAMP ATTORNEYS

for the due and proper payment of the amount of

R___________________________ (_____________________________________)
(hereinafter referred to as "the Principal Debt")

by reason of monies loaned and advanced to the Debtors by the Creditor, , ____________________
and ____________________furthermore declare that we are bound by the conditions set out
hereunder:

1. The Debtors hereby expressly renounces the benefits of the non causa debiti, the errore calculi,
the revision of accounts, no value recorded, and, if there is more than one Debtors, the de duobos
 vel pluribus reis debendi or the ordinis seu excussionis etdivisionis whereof I hereby declare
myself to be fully acquainted.

2. The capital amount of R___________________________ (__________________________)
shall bear interest of R___________________________
(_____________________________________), the total amount owing will amount to
R___________________________ (_____________________________________).

4. The Debtors shall repay an amount of R___________________________

(_____________________________________), over a period of _______ months in
instalments of R___________________________ (__________________________________),
first payment to commence on or before the 7 th of each month, first payment to commence on or
before __________________ 2014.

5. Should any payment due in terms hereof not be made on the due date the Creditor may regard the
balance of the Principal Debt and interest owing in terms hereof as due and payable
immediately, and may issue summons therefore in any competent court without further notice
of demand to the Debtors.

6. The Principal Debt shall become due and payable immediately in the event of the insolvency of
the Debtors, or if the Debtors commits an act of insolvency.

7. Any certificate issued under the signature of the Creditor or his duly authorized agent that
purports to certify the amount due hereunder shall be accepted as prima facie proof of such
indebtedness and shall have sufficient probative value to enable the Creditor to obtain summary
judgment or provisional sentence against the Debtors in any competent court for the amount
stated in such certificate, and the Debtors accepts the onus of disproving the amount so stated
as not being the amount owing.

8. This agreement is not a novation of any existing debt or liability.

9. The DEBTORSS confirms that the following particulars are correct:

FULL NAMES :
REGISTRATION NUMBER :
RESIDENTIAL ADDRESS :

TELEPHONE NUMBERS : CELL:

TELL:

FULL NAMES :
IDENTITY NUMBER :
RESIDENTIAL ADDRESS :
 TELEPHONE NUMBERS : CELL:

THUS DONE and SIGNED at _________________ on this ____ day of _________________ in the
presence of the undersigned witnesses:

AS WITNESSES:

1. _________________________

_________________________

2. _________________________

AS WITNESSES:

1. _________________________

_________________________

2. _________________________