Declaration of discretion

Information request

Below you find a declaration of discretion and exclusivity for you to fill out, sign and return to us.

To enable us to give you the best possible assistance we ask you to give us an indication of the amount of your own capital that you are intending to invest in the purchase.

Please complete, print and sign the form below and return it to us scanned by mail info@interfrance.nl or by fax on number: 0031-84-832.15.81. On receipt of the declaration of exclusivity, we will send you further information and the details you requested as soon as possible.

Kind regards,

The Inter-France team.

* = required

DECLARATION

The undersigned,

name/ names* address* postal code* town* telephone* mobile e-mail* investment own capital* Is this amount available immediately? yes no visiting period* When do you prefer to purchase?*

acknowledge that they have received information and addresses from Inter-France, Groesbeekseweg 259, 6523 NX Nijmegen Holland and/or SARL Inter-France, 12300 Decazeville France, concerning the following real estate situated in France (the numbers refer to the reference numbers used by Inter-France in its publications):

Referencenumber	Price	Description/Area

and agree that for the real estate listed above, to deal exclusively through Inter-France and therefore for these properties not to deal directly with the owner with the aim of a direct or indirect sale. In addition the undersigned declare that they will keep the information provided by Inter-France to themselves and not pass it or any part of it to another.

Signed at (location) on (date)

Signature:

Name: