ACKNOWLEDGEMENT OF DEBT (DAMAGES)

I, the undersigned

Name of Employee: ______________________________________________________________________________

Employee No. or ID No.: ______________________________________________________________________________

Residential Address: ______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Telephone No.: ______________________________________________________________________________

hereby acknowledges and agrees to the following:

1.! That I am truly and lawfully indebted to my Employer

_______________________________________________________________________________________
(Employer name)
in the amount of R____________________ (________________________________________________),
due to the following reason:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________

2.! To repay the above outstanding amount to the Employer in monthly instalments of R__________________
(____________________________________________________), which instalments due may be deducted by
the Employer from my monthly salary, starting from _______________________________ (date), until the full
outstanding amount has been settled.

3.! That should I cease to be employed by the Employer, then the full outstanding amount owing to the Employer
will immediately become due and payable. In such event, I consent to the Employer using my accrued
salary, pension money and / or leave pay due to me to settle the full outstanding amount owing to the
Employer, by means of set off.

4.! Should the above amount due to me by the Employer however not be sufficient to settle the full outstanding
amount owing to the Employer, I agree to repay the remaining outstanding amount due to the Employer by
means of payment to the Employer of the above monthly instalments, starting from the 1st of the month
following my termination date and thereafter on the 1st of every subsequent month thereafter, until the full
outstanding amount has been settled.

5.! Should I fail to fulfil any of the above terms and conditions of this agreement on the due date thereof, the
Employer shall, without prejudicing any other rights and remedies the Employer may have, have the right to
cancel this agreement and claim immediate payment of the full outstanding amount. I agree that I will be

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 liable for all legal costs (on a scale between attorney and client), including tracing fees and collection
commission, which the Employer may incur in enforcing any rights in terms of this agreement, should I fail
to fulfil any of the terms and conditions on the due date thereof.

6.! I hereby consent to the jurisdiction of the Magistrates Court, but agree that the Employer may institute action
against me in any competent court having jurisdiction.

7.! That no variation of this agreement or consensual cancellation shall have any force or affect, unless it is
recorded in writing and signed by both parties.

8.! That the rights of the employer in terms of this agreement shall in no way be curtailed, affected or prejudiced
in consequence of any concession made or indulgence granted by the Employer to me, in respect of my
fulfilment of any of my obligations in terms of this agreement.

9.! This agreement constitutes the entire agreement between myself and the Employer and all the terms and
conditions hereof shall be deemed to be material.

Signed at _________________________ on this _____ day of _________________ 20__.

WITNESS:

_________________________ _________________________
EMPLOYEE

_________________________

Signed at _________________________ on this _____ day of _________________ 20__.

WITNESSES:

_________________________ __________________________
EMPLOYER

_________________________!

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