Contract No.
This contract applies to the elderly people who have full capacity for civil behavior, but are not able to pay all the expenses by themselves, and need Party C to be the payer of their *** with . In this case, Party C is both the obligor of payment and also the agent and contact person appointed by Party B.
Party A (elderly service organization):
Name:
Legal Representative:
Address:
Telephone:
Postal Code:
Party B (elderly residents):
Name: Sex: Date of Birth:
Identification Card No.
Family Address:
Home Address:
Party B is the person who will be paying the fees. /p>
Party C (payment obligations, including but not limited to Party B's spouse, legal support obligations, other relatives, former work unit or other units or individuals who voluntarily bear the costs of Party B's stay):
(fill in if Party C is an individual):
Name: Gender: ID card no.
Relationship to Party B:
Residence:
Work unit:
Home address:
Work unit:
Work unit:
Work unit:
Working place:
Work Unit:Office Address: Zip Code:
Correspondence Address: Zip Code:
Office Phone: Home Phone:
Mobile Phone:
(If Party C is a unit, please fill in: )
Name:
Legal Representative (or Person in Charge): Contact Person:
Enterprise or Business Legal Entity Registration Number: )
Correspondence Address: Postal Code:
Office Phone:
Given that:
1. Party A (name of the senior care service organization) is a senior care service organization established by law and is capable of providing a series of senior care services such as residence, life care, meals, and psychological/spiritual support services;
2. Party B, Party C After on-site inspection, Party B and Party C voluntarily decide that Party B will move into Party A's (name of the senior care service organization), accept the professional senior care services provided by Party A, and be willing to pay the corresponding fees to Party A;
3. Party B appoints Party C to be its own agent in case of emergency to deal with the relevant matters of Party B under this contract, and Party C agrees to this;
4. Party C voluntarily works with Party B to provide the same services to Party B during the period of stay in Party B's (name of the senior care service organization). * with the burden of Party B in the period of all relevant costs;
In order to create a warm, comfortable, safe living environment, to meet the needs of the elderly "old age, old age," the need to effectively protect the legitimate rights and interests of the elderly, and to clarify the rights and obligations of their respective rights and obligations, according to the "People's Republic of China and the State Law on the Protection of the Rights and Interests of the Elderly No mental illness, no infectious diseases.
2. Admission Procedures:
Party B, who meets the conditions for admission, shall go through the admission procedures in accordance with the following procedures:
(1) Party B shall provide Party A with the Physical Examination Report of the physical examination conducted by hospitals of Grade 2A or above in the city within one month prior to the signing of this contract. (Physical examination items include:
Mental health status, infectious diseases, etc.).
The Medical Examination Report is attached as Annex III to this Contract and will be kept by Party A as Party B's health file for admission to the hospital.
(2) Party B shall provide Party A with the Statement of Health Condition signed by Party B and Party C*** as Attachment IV to this Contract. The statement shall include Party B's past medical history, whether he/she is currently suffering from a disease, psychological and mental condition, and self-care ability.
(3) Assessment of Self-care Ability
Party A, based on the Statement of Health Condition, the Physical Examination Report and the comprehensive assessment of Party B's health condition provided by Party B, the parties agree that the Assessment Report of Self-care Ability shall be attached as Attachment V to this Contract. Based on the assessment report, it is determined that Party B is (choose one of the following three cases):
①Elderly people living on their own ②Elderly people living on their own ②Elderly people living on their own ③Elderly people living on their own ③Elderly people living on their own ③Elderly people living on their own.
(4) If the above conditions are met, Party B will fill out the "Admission Registration Form" (see Annex VI of this contract).
Article II Service Location and Service Facilities
1. The location where Party A provides senior care services is: Beijing District (Specify to the specific door number of the nursing home).
2. The type of room chosen by Party B is (choose one of the following):
① single room ② double room ③ triple room ④ multi-room (more than four people, including four people)
3. The specific room chosen by Party B is: .
Party B based on legitimate reasons to adjust the room, does not involve changes in the type of room, Party A shall try to meet within the scope of the conditions allow. Involving the change of room type, thereby increasing the cost burden, shall also be Party B and Party C to confirm in writing whether to adjust.
4. The service facilities provided by Party A include in-room facilities and public **** facilities, the specific details of which are shown in Annexes VII and VIII of this contract.
Article 3 Service Items and Quality Standards
1. Party A, in accordance with the norms and requirements of the Ministry of Civil Affairs and Beijing Municipality, can provide services such as personal life care, meals, psychological/spiritual support, safety protection and environmental hygiene. The specific scope of services is detailed in Annex IX of this contract.
2. According to the actual situation of Party B, the three parties agree that the service items chosen by Party B are listed in Annex X of this contract.
3. If Party B chooses other service items, or needs to change the service items due to the change of Party B's situation, it will be determined by the three parties through separate negotiation and signing of supplementary contract.
4, Party A to Party B to provide services to the quality standards for (according to the actual situation to choose):
① according to Party A service quality standards
② according to the national or Beijing municipalities in the fulfillment of the contract in the period of the valid norms required to be carried out. If the national or local standards are inconsistent, the higher standard shall be followed.
The service quality standard chosen by both parties is attached as Annex XI to this contract. If there is another agreement on higher service quality standard in this contract, it shall be executed in accordance with the agreement of the contract. If the service quality standard agreed in this contract is lower than the national or Beijing local mandatory standards, it shall be implemented in accordance with the national or Beijing local mandatory standards.
Article 4 Physical Examination
Party A organizes Party B to have a physical examination once a year and informs Party B of the results. Party B has the obligation to cooperate with the medical examination. The cost of medical examination shall be borne by Party B and Party C*** together.
If the doctor suggests Party B to do special examination after the physical examination, Party A shall notify Party B in time, and after obtaining Party B's consent, arrange the special examination for Party B, and the related cost shall be borne by Party B and Party C*** together.
Article 5 Fees and Charges
1. Fees and Charges for Nursing Care Services
(1) The fees and charges for various services provided by Party A for nursing care services are listed in the Annex to this contract.
(2) According to the service items selected in Article 3 of this Contract, Party B's elderly service fee is RMB per month, counting RMB per year. The fee includes , , , , fee (list the fee for each item according to the service item).
(3) If Party B receives other services according to Article 3, item 3, Party A shall charge the fee according to the fee schedule announced in this Article or according to the supplementary contract. In this regard, Party A shall provide Party B or Party C with a Monthly Schedule of Individual Fees, and Party B or Party C shall sign to confirm the breakdown of the fees for the services they have received from Party A. If there are any objections, they may be raised within 7 days after receiving the Schedule of Individual Fees, and Party A shall provide a written explanation.
(4) All relevant fees shall be paid by Party B or Party C, and Party A shall issue a receipt to the payer.
(5) The payment of the above pension service fee shall be made at .
2. Deposit (including occupancy deposit and medical reserve): (If Party A does not require it, then it is not necessary to fill in)
(1) Party B and Party C shall pay at the time of signing the contract a fee equivalent to one month's pension service fee of RMB as an occupancy deposit, which shall be used to pay for delayed payment of the pension service fee, liquidated damages, compensation, and so on.
(2) Party B and Party C shall pay Party A a medical reserve of RMB on the date of signing the contract, which shall be used for the treatment of Party B's sudden and emergency illnesses, the deposit paid to the hospital, and the payment of related expenses.
(3) If the deposit is not enough for the contract period, Party A shall notify Party B and Party C in writing, and Party B and Party C shall make up for it within 10 days from the date of notification.
(4) The deposit and medical reserve shall not bear interest (if interest is charged, the standard of interest shall be indicated), and Party A shall not misappropriate them for other purposes, and they shall be returned to Party B or Party C at the same time of contract termination after deducting the relevant expenses upon expiration of the contract or early termination of the contract.
Article VI Rights and Obligations of Party A
1. Rights of Party A
(1) To collect the relevant fees according to the agreement of this contract;
(2) To manage Party B in accordance with the management system announced in the public notice;
(3) To formulate and modify the management system after consulting Party B.
(4) For the sake of Party B's health and safety, it has the right to adjust the room in which Party B stays in accordance with the changes in the services required by Party B.
(5) For the sake of Party B's health and safety, the right to take emergency measures while notifying Party C in the event of Party B's emergency.
2. Obligations of Party A
(1) Provide Party B with senior care services in accordance with the service quality standards as agreed in the contract;
(2) Provide various service facilities as agreed in the contract, and ensure that senior care service venues and facilities are in compliance with the provisions of the industry standards and operate normally;
(3) Equip with all kinds of qualified service personnel in compliance with the proportion requirement of the law; and (4) in the process of providing services, respect Party B and protect Party B's human dignity and personal and property safety;
(5) try to satisfy Party B's requirement of adjusting the living room as far as possible when the condition permits;
(6) notify Party C or other agreed contact person when Party B's emergency occurs;
(7) Establish a personal file for Party B, in which personal information including Party B's admission registration form, medical examination report and other health information as well as daily expenses and other personal information will be categorized and kept in a complete manner. Except for providing inquiries and copies to Party B, Party C and other authorized departments (Public Security Bureau, Procuratorate, Court, and authorities in charge of the senior care service industry due to the need for case handling, supervision, and inspection), it shall not be disclosed to the public.
(8) Allow Party C and relatives and other persons authorized by Party B to visit Party B and provide convenience;
(9) In case Party B and Party C are unable to pay for senior care services, properly resettle Party B in accordance with the law.
(10) Accepting the reasonable suggestions and supervision of Party B and Party C to Party A.
Article 7 Rights and Obligations of Party B
(1) Rights of Party B:
1. To obtain the senior care services provided by Party A in accordance with the agreed service items and in conformity with the service standards;
2. To have the right to criticize and make suggestions on the services provided by Party A;
3. To be informed of the state of his/her own health, expenses, admission records, etc., and to have the right to Check and copy the personal files established by Party A for them;
4. Have the right to know whether the personnel providing services have undergone professional training and have the corresponding qualifications, and have the right to request Party A to correct or replace the service personnel equipped by Party A whose qualifications are not in accordance with the qualification ratios stipulated by the law, or the personnel who are not qualified to provide services;
5. Have the right to request room adjustments if Party A's conditions permit. Request to adjust the room, Party A shall try to meet;
6, Party B has the freedom and right to participate in social activities.
7, enjoy personal freedom in accordance with the law.
8, enjoy the right to privacy, and human dignity and personal and property safety from infringement;
9, the right to ten days' notice to Party A to terminate this contract.
10, the right to obtain timely medical assistance in case of sudden emergency.
(2) Party B's obligations:
1. Before moving in, you should truthfully reflect your situation to Party A, such as temperament, family members, past medical history.
2. After moving in, you should consciously abide by the rules and regulations of the nursing home, accept the management, and take care of the services and facilities provided by us.
3, and other elderly people living in good solidarity.
4, in the acceptance of the elderly services provided by Party A, due to disease diagnosis and treatment of the situation, should be in the treatment period to comply with the doctor's advice, with treatment.
5. Pay the pension service fee according to the agreed time and amount. Occasional expenses such as treatment and first aid expenses shall be settled at any time.
Article 8 Rights and Obligations of Party C
(1) Rights of Party C:
1. Have the right to be informed of Party B's health and enjoyment of services;
2. Have the right to inspect and copy Party B's files in Party A;
3. In case of emergencies, including, but not limited to, the loss of Party B, accidents, and the emergence of health conditions of Party B. In case of emergency, the right to get the relevant information from Party A in the first time;
4, the right to visit Party B;
5, with the consent of Party B, the right to claim rights on behalf of Party B to Party A in case of infringement of rights and interests.
(2) Party C's obligations:
1. Before moving in, Party C should truthfully state to Party A what it knows about Party B's temperament, family members, past medical history and other circumstances that may affect Party A's services;
2. It should communicate with Party B frequently, keep in touch with Party B, and try to satisfy Party B's spiritual needs. At least once a month to visit Party B, for any reason can not come to visit for a long time, should promptly notify Party A;
3, family and unit address, contact information changes, should promptly notify Party A;
4, Party C shall promptly assist Party A to deal with emergencies occurring in Party B;
5, and Party B **** with Party B to pay for all the expenses incurred during the period in which Party B in the Party.
Article IX Special Agreement
1. Handling of emergencies such as diseases or accidents
(1) If Party B suffers a sudden illness or bodily injury during the period of stay, Party A shall notify Party C in a timely manner, and do its best to take the necessary measures to help immediately, and contact 120 or 999 emergency vehicles in a timely manner; if it is necessary to go to the medical institution to give first aid, Party A shall send someone to accompany it. If Party C cannot be contacted in time, it should get in touch with the other contact person identified in this contract as soon as possible to inform the situation.
(2) All expenses incurred therefrom, including but not limited to first-aid expenses, treatment costs, hospitalization deposit, etc., shall be borne by Party B and Party C*** together.
2. Aftercare services and related expenses in the event of Party B's death
(1) If Party B passes away during the validity period of this contract, Party A shall contact Party C in a timely manner, and Party C shall be responsible for the aftercare work and bear the related expenses (or deducted by Party A directly from the deposit).
(2) Party A is responsible for the death certificate, responsible for contacting the funeral parlor, Party C is responsible for bearing (or deducted by Party A directly from the deposit) the aftercare service fee of yuan.
(3) In the event of the situation agreed in this paragraph, if Party A is still unable to contact Party C within three days from the date of written notice, or if Party C does not come to cooperate in dealing with the relevant matters within three days from the date of written notice from Party A even though it has been contacted, Party B and Party C are hereby authorized to carry out the after-death treatment in accordance with the principle of reasonable goodwill and in conformity with the principles of public order and morals, including but not limited to cremation of the body, storage of ashes, etc., and the expenses incurred will be borne by the funeral parlor. Party B and Party C hereby authorize Party A to carry out after-death treatment in a reasonable and good faith manner and in accordance with public order and morals, including but not limited to cremation of the remains, storage of ashes, etc., and all expenses incurred shall be borne by Party C (or deducted by Party A directly from the deposit).
3. Party C and Party A break contact.
(1) If the contact address or method provided by Party C is inaccurate or undetailed, or if Party C fails to notify Party A in time after the change, or for other reasons, Party C is unable to contact Party C in time, and such a situation lasts for one month consecutively, then it is regarded as a break in the contact. If the interruption of contact lasts for two months, Party A shall have the right to re-establish the contact person after consultation with Party B, but Party C shall not be exempted from its obligations.
(2) If Party C defaults on the payment of any fees in the case of interruption of contact, Party A has the right to sue Party C and the person or organization who has the obligation to support Party B. Party C shall bear all the costs incurred, including but not limited to the arrears of the pension service fee, liquidated damages, compensation, litigation costs, legal costs paid by the lawyer hired by Party A, and all costs paid for the recovery of the loss. All expenses.
4. Burden of responsibility for special circumstances
(1) Party B shall bear the responsibility for any damages caused by Party B's disobedience to Party A's management, disobedience to Party A's advice or non-acceptance of Party A's services, or consumption of food purchased outside the home, or food sent to Party B by visiting relatives or friends. Party A shall promptly notify Party C in case of the above circumstances.
(2) If Party B falls ill or passes away due to her own health reasons during the validity of this contract, Party A shall actively rescue and treat her within the scope of the services provided and her own ability, but shall not be responsible for her illness or death.
(3) If Party B suffers injury due to force majeure, the consequences shall be borne by Party B and Party C.
5. The agreement on the rights and obligations of Party B and Party C in this contract does not exempt other persons who have legal obligations to support Party B from their legal responsibilities.
Article X: Changes and Cancellation of the Contract
1. Changes of the Contract
(1) According to the changes of Party B's health condition, Party A may propose to change the service items and notify Party B and Party C in writing, and Party B and Party C shall confirm in writing the new service items and charges, and if there is any disagreement, may, within 15 days after receiving the notice, put forward the cancellation of the contract in written form. Party B and Party C shall confirm the new service items and charges in writing. If Party C neither confirms nor raises objection after receiving Party A's written notice of change of service program, Party A has the right to choose to adjust the service program according to Party B's health condition or to terminate the contract. If Party A chooses to continue to provide senior care services according to the adjusted service program, Party B and Party C shall be obliged to pay the senior care service fees after the adjustment of service program. If Party B and Party C refuse to pay the service fee according to the adjusted service program, Party A has the right to terminate the contract and charge the service fee for the service already provided.
(2) When the market price of food or labor directly related to Party A's daily management and services increases (based on the data published by the National Bureau of Statistics, the year-on-year increase of food price is more than %, and the year-on-year increase of CPI (Consumer Price Index) is more than %), Party A has the right to appropriately adjust the charges within the increase range, and notify Party B and Party C of the price adjustments in writing 30 days prior to the price adjustment. Party B and Party C.
Party B or Party C has objections to the price adjustment, may within 15 days after receipt of the notice in writing to terminate the contract; Party B or Party C has objections but request to continue to perform the contract in accordance with the original tariffs, Party A has the right to propose the termination of the contract. In both cases, Party A, Party B and Party C shall not be liable to each other for breach of contract.
If Party B or Party C does not raise objection in writing within 15 days after receiving the notice, but refuses to pay the relevant fees according to the adjusted price, Party A has the right to terminate the contract and collect the fees for the services already provided according to the original fee schedule.
2. Termination of the contract
This contract can be terminated under the following circumstances:
(1) If the services provided by Party A do not conform to the contract, or if Party B's person or property is damaged due to Party A's or Party A's staff's fault, Party B has the right to propose to terminate the contract.
(2) If Party B and Party C default on all charges for more than two months without any reason, Party A has the right to terminate the contract, notify Party B and Party C in writing, and request Party B to be discharged. If Party B is not discharged from the hospital within 7 days after Party A has issued the notice of termination of contract, Party A has the right to file a lawsuit and request the court to confirm the termination of the contract. If the contract is canceled in this case, Party B and Party C shall, in addition to the payment of the delinquent service fee and the pension service fee during the litigation period, pay a liquidated damages equivalent to one month's service fee, and bear all the expenses incurred therefrom, including, but not limited to, litigation costs, lost wages of Party A's personnel, and the actual expenses incurred by Party A in hiring attorneys.
(3) Party B seriously violates Party A's rules and regulations, Party A has the right to terminate the contract.
(4) In the event of force majeure or bankruptcy of Party A, resulting in Party A's inability to fulfill the contract, Party A shall, after notifying Party C, assist Party B in transferring to another nursing home or sending back to Party B's residence.
(5) If Party B is hospitalized due to illness, Party A shall take the initiative to ask Party B whether to terminate the contract with Party A. In this case, Party B may terminate the contract and shall not be liable for the breach of contract in case of early termination of the contract. If Party B does not propose to terminate this Contract but requests to keep the bed or room, Party B shall pay the usual fees to Party A as usual.
(6) If the three parties cannot reach an agreement due to Party A's proposal to adjust the senior care service items and/or charges, Party B may propose to terminate the contract.
(7) If Party B is not adapted to the living or management environment, it can propose to terminate the contract ten days in advance, and does not need to bear the responsibility of breach of contract. Party A shall settle the payment and return the deposit (if any) within ten days.
Article 11: Liability for breach of contract
1. If Party B suffers personal or property loss due to Party A's or Party A's staff's fault, Party A shall be responsible for compensation.
2. If Party A fails to provide the service as agreed, it shall reduce the service fee accordingly; if it causes personal or property damage to Party B, it shall also compensate Party B for the actual loss.
3. If the proportion of Party A's qualified service personnel does not meet the requirements of the law, or the services provided are not qualified, and Party A does not correct or improve the services in a timely manner to reach the qualified ones upon Party B's or Party C's proposal, Party B or Party C, after written authorization by Party B, has the right to terminate the contract and request Party A to reduce the charges for the unqualified services, and shall also be liable to pay compensation for any damage to Party B's person or property caused by the unqualified services. Liability.
4. If Party A or its staff violates Party B's privacy or human dignity, causing Party B's mental damage, Party A shall bear the responsibility of compensation.
5. If Party A or its staff violates Party B's and Party C's right to know about the senior care services provided by Party A, Party B and Party C have the right to request Party A to make corrections and bear all the costs incurred by Party B and Party C for exercising the right to know. Party B and Party C shall also compensate for the losses caused by Party B and Party C
6. If Party B and Party C do not pay the fees according to the agreed time, in addition to making up the outstanding fees as soon as possible, Party B and Party C shall also bear the responsibility of defaulting on the overdue fees, specifically: three ten-thousandths of one percent of the liquidated damages for every one day of overdue payment.
7. If Party B violates the rules and regulations formulated by Party A and causes injuries to itself, Party B shall bear the full responsibility by itself; if it causes personal or property losses to a third party (including but not limited to other elderly people or relatives of the hospitalized people, Party A's employees, visitors, etc.), Party B shall bear the legal responsibility and Party C shall bear the joint and several responsibility for it.
8, except for force majeure, Party B, Party C's fault or otherwise agreed in this contract, Party A proposes to terminate the contract, shall pay liquidated damages to Party B, the specific standard of liquidated damages is: .
9, Party A needs to cease business, transfer, need to notify Party B, Party C three months in advance, and the proper placement of Party B in accordance with the law.
Article XII Disclaimer
Force majeure causes Party A to be unable to fulfill this contract, Party A shall promptly notify Party B and Party C after the occurrence of the force majeure event, and this contract shall be automatically terminated, and the parties shall not be responsible for the termination of the contract. Party A and Party C shall actively coordinate and, according to Party B's wishes, choose to properly resettle Party B in the following manner: assisting Party B to transfer to other nursing homes or sending back to Party B's residence.
Article XIII Term of Contract
After consultation, it is determined that the term of this contract shall be for a period of years (months), starting from the month of January to the month of January.
Article XIV Handling of Contract Expiration
1. 30 days before the expiration of the contract, Party B and Party C may **** the same application for renewal of the contract.
2. If Party B and Party C do not ****together apply for renewal of the contract before the expiration of the contract, Party B shall move out of Party A on the expiration date of the contract, go through the procedure of discharge and settle all the expenses.
No relatives or friends of Party B shall have the right to take Party B out of the hospital except Party C and those authorized by Party B in writing.
3, after the expiration of the contract, Party B neither proposed to renew the contract nor move out of Party A, the contract will be changed to an open-ended contract; Party A, Party B and Party C will still perform according to the content of the original contract.
If Party B or Party C refuses to fulfill the original contract, Party A has the right to terminate the contract and notify Party B and Party C in writing of the termination of the contract, and request Party B to move out. If Party B does not move out of the nursing home within 7 days after Party A has issued the notice of termination of the contract, it will be handled in accordance with Article 10, paragraph 2 (2) of this contract.
Article 15 Notice
The addresses and contact information of Party A, B and C indicated in this contract are the valid mailing addresses and contact information of each party. A party shall promptly notify the other parties of any change of mailing address and contact information.
Documents issued by a party that has not been notified of the change of mailing address without timely notification to the other parties shall be deemed to have been delivered if the documents issued by the party that has not been notified of the change of mailing address cannot be delivered.
A registered letter, express mail, or telegram sent by one party to the other party's mailing address is deemed to have been served if it is returned to the party on the grounds that the address is unknown or unavailable, or if the addressee refuses to accept it.
While Party B is staying with Party A, Party A shall deliver a written notice directly to Party B on matters relating to the performance of this Contract before the notice is deemed to have been served on Party B. If Party B refuses to sign the document of service, it shall be deemed to be served if it is signed by two or more elderly residents.
Article XVI Dispute Resolution and Jurisdiction
Disputes arising out of this contract shall be resolved through negotiation as far as possible, and in the event of failure of the negotiation, the People's Court shall have jurisdiction over the place where Party A is located.
Article 17 Annexes
The following documents shall be annexed to this contract:
1. A copy of Party A's legal registration document with Party A's official seal
2. A copy of Party B's and Party C's ID cards and household registers, and Party C's copy of Party C's legal registration document with its official seal if Party C is an organization
3. The "Medical Examination Report" issued by a hospital of Grade 2A or above. Hospital issued by the "physical examination report" (physical examination time within one month)
4, Party B and Party C signed on Party B's "statement of health status" and "check-in registration form".
5, Party A issued by Party B and Party C signed by the recognition of the "self-care ability assessment report"
6, room equipment table
7, public **** facilities and equipment table
8, the scope of Party A's services table
(Party A should be in accordance with the "quality of service norms of the elderly care institutions, fill in the specific service items, such as personal life care services) Including: assisting in washing face, brushing teeth, hairdressing, etc.)
9. Service items chosen by Party B
10. Service Quality Standards for Nursing Care Institutions
11. Charges for various service items of Party A's nursing care services
12. Notes on Admission to Beijing xxxxx Nursing Home and rules and regulations formulated by Party A are attached as an annex to this contract.
13, Party A, B and C signed and sealed "Supplementary Agreement".
Article XVIII Effective
This contract is made in triplicate, one for each party A, B and C, with equal legal effect, and shall come into effect upon signature or seal of each party.
Party A: (official seal)
Legal representative (signature):
Date:
Party B (signature, seal or handprint):
Date:
Party C:
(signature, seal or handprint)
Date: