Farm Debt Mediation Unit

Farm Debt Mediation Unit

FARM DEBT MEDIATION ACT 1994 (NSW)

FORM 4–APPLICATION FOR SECTION 11 CERTIFICATE

Creditor to complete:

Section 11 of the Farm Debt Mediation Act 1994 (NSW) provides that the Authority must issue a certificate that the Act does not apply to a farm mortgage if the requirements of the Act have been met.

______
[creditor]

______
[address]

______
[email] [phone]

is applying for a section 11 Certificate under the Farm Debt Mediation Act 1994(NSW) for exemption from the Act for the farm mortgageunder which the farmer is in default, described as

______
[description of farm mortgage]

FACILITY / BALANCE OUTSTANDING
as at date of issue of Form 1 – Section 8 Notice

taken out by ______[name of farmers]

of ______[address of farmers]

upon the grounds set below:[please indicate which ground is applicable]

/ 1. / Satisfactory mediation has taken place in respect of the farm debt involved.
Please attach a copy of the heads of agreement entered into at the mediation [if there is one] including the cooling-off period statement.
2. / The farmer has declined to mediate: [please advise the grounds it is alleged the farmer has declined to mediate]
/ (a) / The farmer has failed to take part in mediation in good faith or has unreasonably delayed entering into or proceeding with mediation
(b) / The farmer has indicated in writing to the Authority or to the creditor that the farmer does not wish to enter into or proceed with mediation in respect of the debt concerned;
/ to Authority
/ to Creditor
date of document ______/ ______/ ______
/ (c) / The farmer has failed to respond, in writing, within 28 days to an invitation in writing to the farmer by the creditor to attend a mediation session.
/ 3. / Three months have elapsed since the creditor gave the farmer a Form 1 – Section 8 Notice and the creditor has throughout that period attempted to mediate in good faith [whether or not a mediation session or satisfactory mediation took place during that period.]
Name of farmercontact:
Address for contact:
Farmer’s contact phone number:

NOTE:Satisfactory evidence about the ground relied onin the Farm Debt Mediation Act 1994 (NSW) must be provided to the Authority. This may include:

•a certified copy of the Form 1 – Section 8 Notice to Farmer;

•a certified copy of the Form 2 – Section 9 Notice to Creditor;

•confirmation from the mediator that "satisfactory mediation" has taken place;

•copies of correspondence between or among the parties;

•copies of any invitations to commence mediation issued in terms of section 11(2)(c) of the Act;

•a statutory declaration setting out the facts which are considered to constitute grounds for claiming under a particular provision, or

•a list of the dates on which the creditor contacted the farmer by telephone regarding available mediation dates.

Signed: ______

Date: ______/______/ ______

To assist with the processing of this application please complete and return a Form 12 – Consent Formand enclose a completed Consent Form from the Farmer.

Please return completed form to Creditor:

______

______

______

______

______

Authorised forms for creditor-initiated mediation can be downloaded from

NSW Rural Assistance Authority Form 4 – Application for Section 11 Certificate V2.0 04/17 Page 1 of 2