Attn. [the commissioner of justice (formerly bailiff and judicial auctioneer) shall insert here his name, geographical address and, where available, fax number and e-mail address]  :

I/ We (*) hereby notify you/ Notify you (*) my/ our (*) refusal to participate in the simplified procedure for the recovery of an amount of [total amount claimed] consisting of:

- [total principal amount]

- [total amount of interest]

invoked by [Madam, Sir or corporate name of the creditor] on the basis of [basis of claim: date of contract or obligation of a statutory nature] .

Signature of consignee(s) (only in case of notification of this form on paper).

(*) Strike out what does not apply.