Form 10

VICTORIAN FARM DEBT MEDIATION ACT 2011

APPLICATION FOR PROHIBITION CERTIFICATE
UNDER SECTION 13

To: Victorian Small Business Commission
Level 2, 121 Exhibition Street
Melbourne VIC 3000
GPO Box 4509, Melbourne VIC 3001
DX 210074 Melbourne / Phone:13 VSBC (13 8722)
Toll Free:1800 136 034
TTY: 03 9651 7596
Fax: 03 9651 9943 / Email:
Website: www.vsbc.vic.gov.au

______

[name of applicant farmer]

______

[address of applicant farmer]

hereby make application pursuant to Section 13 of the Victorian Farm Debt Mediation Act 2011 for a prohibition certificate for the farm mortgage described as

______

______

[Description of farm mortgage]

FACILITY

Given to______

[name of creditor]

______

[address of creditor]

upon the grounds set out below:

1. / The farmer is in default under the farm mortgage
2. / The farmer has requested the creditor to mediate in respect of the farm debt
3. / The creditor has actively refused to mediate
or
The creditor has failed to respond to the farmer’s request to mediate and at least 21 days have elapsed since the request was made
or
The creditor has refused to continue to mediate
or
At least 3 months have elapsed after a request was made by the farmer under section 9(1) or (2) and throughout that period the farmer has attempted to mediate in good faith but no satisfactory mediation has taken place between the farmer and the creditor

Other relevant information

______

______

______

______

Name of contact creditor: ______

Address for contact: ______

Creditor’s contact telephone number: ______

NOTE: Satisfactory evidence as to the failure of the creditor to enter into farmer-initiated mediation must be provided to the Victorian Small Business Commission. This may include:

• A certified copy of the section 9(1) Notice (form 2) or the Section 9(2) Notice (form 7) sent to the creditor.

• Copies of correspondence between the parties.

• A statutory declaration setting out the facts which are considered to constitute grounds for claim.

• A list of the dates on which the farmer contacted the creditor by telephone regarding farmer-initiated mediation.

Signed: ______

Dated: _

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Victorian Small Business Commission Version 4, 07/17