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Claim No.

Section D

I object to the claimant issuing under this procedure

My reasons for objecting are:

Section E

I intend to rely on written evidence

My written evidence:
is filed with this form
will be filed within 14 days as agreed with the other party(ies). A copy of the written agreement is
attached to this form

Section F

Full name of defendant filing
this acknowledgment

Section G

Signed *(I believe)(The defendant believes) that the facts stated in Position or
(To be signed by this form are true. *I am duly authorised by the defendant office held
you or by your to sign this statement (if signing on
solicitor or behalf of firm
litigation friend) or company)

*delete as appropriate

Date

Give an if applicable
address to
which notices Ref. no.
about this case
can be sent to
you fax no.

DX no.
Postcode

Tel. no. e-mail

82