Steinhoff Global Settlement

Online Claim Form (Individual Parties)

Part 1. Terms and Conditions

These Terms and Conditions govern this Claim Form. You must read these Terms and Conditions in detail and consider seeking independent legal advice prior to completing the Claim Form.

1.1 Agreement with the terms

By submitting this Claim Form electronically and clicking "submit signature", you are bound by the terms of this Claim Form as of the date of this Claim Form, as included in these Terms and Conditions, all Parts and the Annex of this Claim Form.

1.2 Applicability of the Proposals

The completion and submission of this Claim Form is a requirement under the Proposals. Terms used but not defined in this Claim Form will have the meaning given to them in the Proposals. A list of most used definitions is provided on the following page.

1.3 Acceptance of the SRF and Claims Administration Conditions

By submitting this Claim Form electronically and clicking "submit signature", you accept and acknowledge the SRF and Claims Administration Conditions, including the stipulations set out in clauses 3.1.1 through 3.1.18 of the SRF and Claims Administration Conditions which are all applicable and include amongst others, exclusions of liability for the benefit of SRF, as well as its individual (current and former) board members and supporting staff of SRF, as set out in clauses 3.1.6, 3.1.7 and 3.1.10 of the SRF and Claims Administration Conditions.

1.4 Waivers and releases

By submitting a signed Claim Form, you accept and acknowledge (and as the case may be perfect) the waivers and releases to SRF, as well as its individual (current and former) board members and supporting staff of SRF that are included in the SIHNV Composition Plan (as amended) and/or the SIHPL Section 155 Proposal (as amended) to the extent they are not already binding by operation of law. The confirmations contained herein shall not impair or diminish the binding nature of such waivers and releases in the SIHNV Composition Plan (as amended) or the SIHPL Section 155 Proposal (as amended) whether by operation of law or otherwise.

1.5 No transfer or assignment

By signing and submitting this Claim Form, you agree and acknowledge that as of the date of submission of this Claim Form you shall not assign or transfer any rights or obligations in relation to or arising from your MPC Relevant Claims and the Proposals, and any such rights or obligations are incapable of being transferred or assigned.

1.6 Electronic communication

By submitting this Claim Form, you authorise the Claims Administrator to communicate with you only electronically via the email address provided below for all future communications in connection with this Claim Form, the MPC Relevant Claims and the Proposals.

1.7 Completed Claim Form required

This Claim Form must be completed, filled out in whole and signed before submission. Blank forms will not be accepted

1.8 Change to details provided

To the extent the contact or bank details provided in Part 6.B and 8.B change, you must immediately provide an update to SRF c/o the Claims Administrator via email at info@steinhoffsettlement.com.

Failure to do so is at your risk and expense. You bear the risk that any details provided in this Claim Form are incorrect.

1.9 Submission by joint account holders

Where two or more people own, or are the beneficiaries of, the brokerage account on which you hold or held your Steinhoff Shares, only one Claim Form can be submitted in respect of such shares on behalf of the joint holders or beneficiaries together. Such Claim Form needs to be signed – to the extent applicable - by or on behalf of all joint owners, co-beneficiaries and co-owners. If a joint holder also in its individual capacity holds a Claim, it can submit a separate Claim Form.

1.10 Multiple Claims

You acknowledge and agree that: (i) you may only submit one Claim per natural or legal person; (ii) you are not permitted to submit multiple Claims for multiple accounts owned by the same natural or legal person; and (iii) where you do own multiple accounts (in the same capacity, i.e. under the same name), the Claims in respect of these accounts have to be aggregated into one Claim Form. This does not apply to a Claim held in the capacity of a joint owner / beneficiary and a Claim held in an individual capacity (see above para. 1.9).

1.11 Payment by SRF

By filling in this Claim Form, you irrevocably and explicitly consent to SRF determining the eligibility, validity and amount of a Claim for compensation and to SRF paying compensation, each in accordance with the Proposals (as applicable) and the SRF and Claims Administration Conditions.

1.12 Governing law

This Claim Form is governed by Dutch law.

Part 2. Most used definitions

"Allegations" means the allegations set out in Schedule 11 (The Allegations) to the SIHNV Composition Plan;

"Audit Firms" means an audit firm performing or having at any time performed audit and other services for SIHNV, SIHPL, any other Steinhoff Group Company or related entities, and/or any external valuation professional and/or any third parties that undertook a materially similar role as well as any other audit firm which is a member of the same network of firms, including but not limited to Deloitte Accountants B.V., Deloitte & Touche South Africa and Deloitte Touche Tohmatsu Limited and any other firm which is a member or affiliate of the Deloitte Touche Tohmatsu Limited network of firms, and any of their current and former partners, principals, shareholders, auditors, directors (managing or supervisory), officers, employees, direct or indirect holding company (or companies), affiliates and direct or indirect Subsidiaries, successors and assigns;

"Bar Date" means the date falling three months after the Settlement Effective Date;

"Claim" means a claim of any nature, whether present or future, whether actual, prospective or contingent, whether in existence now or coming into existence at some time in the future (including those which arise upon a change in the relevant law), whether known or unknown and whether contemplated or not, including (without limitation):

  1. any and all claims, rights, demands and causes of action, including in respect of any Liabilities, obligations or losses and whether arising in equity or under common law or statute or by reason of breach of contract, breach of trust or in respect of any tortious or negligent act or omission (whether or not loss or damage caused thereby has yet been suffered), or in restitution or by way of proprietary claim or otherwise;
  2. claims for, among other things, the enforcement of any right to, or any Liability in respect of a right to:
    1. seek or enforce judgment;
    2. exercise any remedy (for damages or otherwise), indemnity and contribution, whether for losses (including consequential loss, economic loss, loss of bargain, loss of value, or other losses computed by reference to value which may have been available had an obligation been duly performed in a timely manner, or otherwise), costs, charges and expenses of any nature;
    3. seek the filing of papers, or the production, disclosure or discovery of any document or thing; or
    4. apply any set-off, netting, withholding, combination of accounts or retention or similar rights in respect of any claim or any Liability; and
  3. a claim of any nature arising out of or in relation to any negligent, reckless, intentional, dishonest or fraudulent act or omission;

"Claim Determination" means the decisions made by the SRF:

  1. whether to accept or reject a Claim filed by an MPC Claimant or SIHNV Contractual Claimant (as defined in the SIHNV Composition Plan); and
  2. if accepted, the Claim Value of that Claim;

"Claim Value" means the nominal value attributed to:

  1. the Claim of an MPC Claimant in accordance with the Steinhoff Allocation Plan; and
  2. the Claim of any other Distribution Creditor (as defined in the SIHNV Composition Plan) in accordance with the Valuation Principles;

"Claimant Representative" means each of the following parties:

  1. Burford Capital LLC, a limited liability company incorporated under the laws of Delaware with registered number 6607465;
  2. Deminor Recovery Services (Luxembourg) S.à r.l., a company incorporated under the laws of Luxembourg with registered number B175299, and DRS Belgium S.R.L., a company incorporated under the laws of Belgium with registered number 0452 511 928;
  3. Hamilton;
  4. Innsworth;
  5. Grant & Eisenhofer P.A. and Kessler Topaz Meltzer & Check, LLP; and
  6. ISLG.

For the avoidance of doubt: for each of Hamilton and Innsworth, a reference to "Claimant Representative" shall also be deemed to be a reference to Hamilton and Innsworth in their capacity as MPC Claimant, if applicable;

"Claims Administrator" means a globally recognised claims administrator initially appointed by SIHNV and SIHPL (to be replaced by SRF as sole counterparty of the claims administrator after the incorporation of SRF) to act independently from the parties to the SRF Settlement Documents (as defined in the SRF and Claims Administration Conditions) (except for the SRF) and to assist the SRF with the implementation of the SRF Settlement Documents;

"D&O Beneficiaries" means the D&O Insurers and the D&Os;

"D&O Insurers" means the insurance companies and/or Lloyd's syndicates acting for itself and as proxyholder of other insurance companies underwriting Steinhoff's (primary and excess) Directors and Officers insurance policy with no. B080133495P17 and claim reference B080133495P17AAA (primary), B080133495P17AAB (first excess), B080133495P17AAC (second excess), B080133495P17AAD (third excess) and B080133495P17AAE (fourth excess);

"D&Os" means all directors, officers and other personnel of Steinhoff Group Companies and/or former Steinhoff Group Companies who work or have in any way or another worked for or been associated with a Steinhoff Group Company and/or former Steinhoff Group Company;

"DBA" means the Dutch Bankruptcy Act (in Dutch: "Faillissementswet").

"Deloitte Beneficiaries" means the Deloitte Firms and Deloitte Touche Tohmatsu Limited and any other firm which is a member or affiliate of the Deloitte Touche Tohmatsu Limited network of firms and any of their current and former partners, principals, shareholders, auditors, direct or indirect holding company (or companies), and direct or indirect Subsidiaries, affiliates, members, partners, employees, officers and directors (managing or supervisory) of any of the aforementioned entities and their respective successors in title and assigns;

"Deloitte Firms" means Deloitte NL and Deloitte & Touche South Africa;

"Dispute Committee" means a dispute committee with exclusive jurisdiction to decide on all matters and disputes between SRF, an MPC Claimant, an SIHNV Contractual Claimant (as defined in the SIHNV Composition Plan) and/or SIHNV/SIHPL in relation to the question of whether and to what extent an MPC Claimant or SIHNV Contractual Claimant is entitled to compensation from the SoP Settlement Fund pursuant to the SIHNV Composition Plan, including the relevant Claim Determination, by way of binding advice (in Dutch: "bindend advies") under Section 7:900 et seq. of the Dutch Civil Code in accordance with the Dispute Committee Rules (as defined in the SIHNV Composition Plan);

"Events" means certain events that are or may be alleged to have occurred in relation to alleged mismanagement (in Dutch: "wanbeleid"), accounting irregularities, market manipulation, misstatements, misrepresentation of and otherwise misleading annual accounts and other financial reporting, including in prospectuses published (such as the 2015 Prospectus, as defined in the SIHNV Composition Plan) by and/or other public statements made by Steinhoff Group Companies and/or former Steinhoff Group Companies, as well as in relation to allegations of improper fulfilment of duties by any Audit Firms, managing or supervisory directors, officers and/or employees of Steinhoff Group Companies and/or former Steinhoff Group Companies and other matters, whether such allegations are known or unknown at the date of the SIHNV Composition Plan;

"FSE" means the Frankfurt Stock Exchange;

"Inflation Methodology" has the meaning given to it in the Steinhoff Allocation Plan;

"JSE" means the Johannesburg Stock Exchange;

"Liabilities" means all liabilities, duties and obligations of every description, whether known or unknown, whether deriving from contract, common law, case law, legal provisions, statute or otherwise, whether present or future, actual or contingent, ascertained or unascertained or disputed and whether owed or incurred severally or jointly or as principal or surety, and including arising out of or in relation to any reckless or fraudulent act or omission, and "Liability" means any one of them;

"MPC Claimant" means an SIHNV MPC Claimant or a SIHPL MPC Claimant;

"MPC Relevant Claim" means an SIHNV MPC Relevant Claim or a SIHPL MPC Relevant Claim;

"Scheme of Arrangement" means the scheme of arrangement under the laws of South Africa, completed on 7 December 2015, pursuant to which SIHNV acquired the entire share capital in SIHPL through the issue of one ordinary share in its capital in exchange for each ordinary share in the capital of SIHPL;

"Section 155 Meeting" means the meeting, or meetings, of "Scheme Creditors" (as defined in the SIHPL Section 155 Proposal), as the case may be, to be convened in accordance with section 155(6) of the South African Companies Act (2008), as may be adjourned from time to time. The date(s) of the meeting(s) will be announced on www.steinhoffsettlement.com;

"Section 155 Proceedings" means compromise proceedings under section 155 of the South African Companies Act 71 of 2008, which will broadly be used to implement the settlement of claims by specified classes of creditors against SIHPL;

"SIHNV Composition Plan" means the draft composition plan (in Dutch: "ontwerpakkoord") originally dated 15 February 2021, substantially in the form as submitted by SIHNV together with its application for the SoP Proceedings dated 15 February 2021 and as may be amended until the court hearing scheduled pursuant to Section 255(1)(2°) DBA;

"SIHNV MPC Claimant" means each person who:

  1. has an SIHNV MPC Relevant Claim;
  2. has validly acquired or been assigned an SIHNV MPC Relevant Claim; or
  3. is otherwise accepted as such by SRF or SIHNV,

but excluding:

  1. the Contractual Claimants with respect to their Contractual Relevant Claims (as each is defined in the SIHNV Composition Plan);
  2. any Steinhoff Group Company;
  3. any Excluded Individuals (as defined in the SIHNV Composition Plan), any legal successors of the Excluded Individuals and any legal entities related to or controlled by any Excluded Individual; and
  4. Christoffel Hendrik Wiese, any legal entities related to or controlled by him and all persons that have or had in the past a direct or indirect shareholding in Upington (as defined in the SIHNV Composition Plan);

"SIHNV MPC Relevant Claim" means a Claim:

  1. against SIHNV in relation to the Events and/or the Allegations, arising as a result of a person purchasing (as defined below) SIHNV Shares on the JSE or FSE between 6 December 2015 c.o.b. and 5 December 2017 c.o.b. (even if the SIHNV Shares were not delivered to the purchaser's securities account by 5 December 2017 c.o.b.), and holding those shares at 5 December 2017 c.o.b.; and
  2. with a positive Claim Value calculated in accordance with the Inflation Methodology;

For the purposes hereof, a "purchase" will have the meaning ascribed thereto in the Steinhoff Allocation Plan;

"SIHNV Shares" means ordinary shares in the capital of SIHNV listed on the JSE and FSE;

"SIHPL MPC Claimant" means each person who:

  1. has a SIHPL MPC Relevant Claim;
  2. has validly acquired or been assigned a SIHPL MPC Relevant Claim; or
  3. is otherwise accepted as such by SRF or SIHPL,

but excluding:

  1. the Contractual Claimants with respect to their Contractual Relevant Claims;
  2. any Steinhoff Group Company;
  3. any Excluded Individuals, any legal successors of the Excluded Individuals and any legal entities related to or controlled by any Excluded Individual; and
  4. Christoffel Hendrik Wiese, any legal entities related to or controlled by him and all persons that have or had in the past a direct or indirect shareholding in Upington;

"SIHPL MPC Relevant Claim" means a Claim:

  1. against SIHPL in relation to the Events and/or the Allegations, arising as a result of a person purchasing (as defined below):
    1. SIHPL Shares listed on the JSE between 2 March 2009 o.o.b. and 6 December 2015 c.o.b. (which were subsequently converted to SIHNV Shares pursuant to the Scheme of Arrangement), even if such shares had not yet been delivered to the purchaser's securities account by 6 December 2015 c.o.b., and holding such SIHNV shares at 5 December 2017 c.o.b.; or
    2. SIHPL Shares listed on the JSE prior to 2 March 2009 o.o.b. (which were subsequently converted to SIHNV Shares pursuant to the Scheme of Arrangement) and holding such SIHNV Shares until 5 December 2017 c.o.b. on the basis of the last in first out matching process described in par. 20 of the Steinhoff Allocation Plan; and
  2. with a positive Claim Value calculated in accordance with the Inflation Methodology.

For the purposes hereof:

  1. a "purchase" will have the meaning ascribed thereto in the Steinhoff Allocation Plan; and
  2. a SIHPL MPC Relevant Claim remains notwithstanding the exchange of the relevant SIHPL Shares into SIHNV Shares pursuant to the Scheme of Arrangement and will not convert into an SIHNV MPC Relevant Claim;

"SIHPL Section 155 Proposal" means the proposal made by SIHPL pursuant to section 155 of the Companies Act No. 71 of 2008 (as amended) to certain of its claimants falling within the definition of Scheme Creditors as set out therein;

"SIHPL Shares" means ordinary shares in the capital of SIHPL listed on the JSE;

"SoP Administrator" means the administrators (in Dutch: "bewindvoerders") as appointed by the District Court of Amsterdam in the SoP pursuant to Section 215(2) DBA, being Mr F. Verhoeven and Mr C.R. Zijderveld;

"SoP Committee of Representatives" means the committee of representatives (in Dutch: "commissie van vertegenwoordiging") as may be appointed by the District Court of Amsterdam pursuant to Section 281e DBA;

"SoP Proceedings" means the Dutch suspension of payment proceedings (in Dutch: "surseance van betaling"), of SIHNV which has been (provisionally) granted by the District Court of Amsterdam on 15 February 2021 (case reference: C/13/21/4-S), which will be used to implement the settlement of claims against SIHNV;

"SoP Settlement Fund" means the settlement consideration of an amount equivalent to €370,000,000.00 (i.e. the "Gross Settlement Fund") less (A) any amounts payable pursuant to clause 4 of the SRF and Claims Administration Conditions and (B) any amounts to be deducted from the Gross Settlement Fund pursuant to the Proposals;

"SRF" means the Stichting Steinhoff Recovery Foundation, a Dutch foundation (in Dutch: "stichting") to be established by SIHNV;

"SRF and Claims Administration Conditions" means the provisions governing the supervision, monitoring, administration and distribution and repayment of, among other things, the SoP Settlement Fund distributable to the SIHNV MPC Claimants as set out in Clause 9 of the SIHNV Composition Plan, and the resolution of disputes on the determination of eligibility and Claim Values, annexed as Schedule 2 (SRF and Claims Administration Conditions) of the SIHNV Composition Plan;

"SSSA" means the Steinhoff Settlement Support Agreement entered into between, among others, SIHNV, SIHPL, the D&O Insurers, the Deloitte Firms and SRF;

"Steinhoff Allocation Plan" means the plan pursuant to which the Claim Value and each share of the SoP Settlement Fund in respect of the MPC Relevant Claims timely and validly filed by the MPC Claimants will be determined, as annexed to the SIHNV Composition Plan as Schedule 3 (Steinhoff Allocation Plan);

"Steinhoff Group Companies" means SIHNV and each of its Subsidiaries from time to time, which includes, for the avoidance of doubt, SIHPL, and "Steinhoff Group Company" means any one of them;

"Steinhoff Group Settlement" means the settlement of (substantially) all of the Claims against SIHNV and SIHPL so as to provide finality for SIHNV and SIHPL, and each other Steinhoff Group Company in relation to those Claims on the terms set out in the Settlement Term Sheet included as Schedule 9 to the SIHNV Composition Plan, as amended by the Proposals (available on www.steinhoffsettlement.com);

"Steinhoff Shares" means SIHNV Shares and/or SIHPL Shares, as applicable;

"Subsidiaries" means in relation to any company, corporation or other legal entity (a "holding company"), companies, corporations or legal entities:

  1. which are controlled, directly or indirectly, by the holding company;
  2. in which a majority of rights are held by the holding company, either alone or pursuant to an agreement with others;
  3. more than half the issued share capital of which is beneficially owned, directly or indirectly, by the holding company; or
  4. which are subsidiaries of another Subsidiary of the holding company,

and "Subsidiary" means any one of them. For this purpose, a company, corporation or other legal entity shall be treated as being controlled by another if that other company, corporation or other legal entity is able to determine the composition of the majority of its board of directors or equivalent body

"Valuation Principles" means the valuation principles as set out in Schedule 7 (Valuation Principles) to the SIHNV Composition Plan;

"Voting Hearing" means with respect to the SoP Proceedings the court hearing scheduled pursuant to Section 255(1)(2 o) DBA, being 30 June 2021, which is set at 10.00 (CET) on 30 June 2021 or a meeting of the SoP Committee of Representatives if so appointed to be scheduled pursuant to Section 281e DBA to be held at the District Court of Amsterdam, located at Parnassusweg 280 in Amsterdam, The Netherlands or at any other venue designated by the District Court; and

"Voting Record Date" means the date scheduled pursuant to Section 255(1)(1o) DBA, which is set on 15 June 2021.

Part 3. Filing instructions

Reference is made to:

  1. SoP Proceedings;
  2. the SIHNV Composition Plan; and
  3. the SIHPL Section 155 Proposal (together with the SIHNV Composition Plan, the "Proposals").

The key terms of the SIHNV Composition Plan may be summarised as follows:

  1. The SIHNV Composition Plan is offered by SIHNV to all its ordinary non-preferred creditors, including claimants holding SIHNV MPC Relevant Claims.
  2. SIHNV will make available to SRF a settlement consideration in the amount of €370,000,000, less certain deductions (the SoP Settlement Fund) in respect of all MPC Relevant Claims (irrespective of whether these are against SIHNV or SIHPL) and certain claimants who received consideration from Steinhoff Group Companies under certain commercial transactions (the SIHNV Contractual Claimants). SRF will administer payments to each MPC Claimant and SIHNV Contractual Claimant from the SoP Settlement Fund on a pro rata basis in proportion to its Claim Value as bindingly determined by SRF in accordance with the Valuation Principles. In order to be eligible for payment each MPC Claimant and SIHNV Contractual Claimant must file its claim with the Claims Administrator on or before the Bar Date in the manner prescribed by the SIHNV Composition Plan and SRF and Claims Administration Conditions.
  3. SIHNV will reserve certain amounts for payments to other (alleged) claimants with unrecognised claims. If and to the extent their claim values are bindingly determined or agreed with SIHNV, such claimants will be entitled to the same recovery as offered to the MPC Claimants and SIHNV Contractual Claimants.
  4. The SIHNV Composition Plan will not affect the rights of certain trade and de minimis creditors, the contractual rights of certain financial creditors and the contractual rights of certain intra-group creditors. These creditors will not be eligible to receive settlement considerations under the SIHNV Composition Plan. Their rights will be preserved as they are.
  5. The ordinary non-preferred creditors release certain claims under the terms of the SIHNV Composition Plan, including against the Steinhoff Group Companies.
  6. The SIHNV Composition Plan will become effective if, amongst other things, it is adopted at the Voting Hearing and confirmed by the District Court of Amsterdam (which confirmation has become final and no longer subject to appeal).

The key terms of the SIHPL Section 155 Proposal may be summarised as follows:

  1. The SIHPL Section 155 Proposal contemplates a compromise between SIHPL and Scheme Creditors, defined in the SIHPL Section 155 Proposal, and who are envisaged to be settled in accordance with the terms of the SIHPL Section 155 Proposal.
  2. The SIHPL Section 155 Proposal shall become effective if (i) it is adopted by the statutory required majorities of the Scheme Creditors of SIHPL that participate in the filing and voting procedures; (ii) it is thereafter approved and sanctioned on a final and non-appealable basis by the High Court of South Africa as contemplated in section 155(7) of the Companies Act; and (iii) all of the Suspensive Conditions (as defined in Annexure A to the SIHPL Section 155 Proposal) applicable to the SIHPL Section 155 Proposal are satisfied. Following the SIHPL Section 155 Proposal becoming effective, compromises will become effective and distributions will be made to the Scheme Creditors who are entitled thereto in accordance with the provisions of the SIHPL Section 155 Proposal. If the SIHPL Section 155 Proposal does not become effective, it shall be of no legal force or effect, shall not constitute a compromise of any claims of Scheme Creditors, and shall not constitute an offer of any kind on the part of the Company capable of acceptance by Scheme Creditors.
  3. Scheme Creditors comprise what are defined in Annexure A to the SIHPL Section 155 Proposal as –
    • the Contractual Claimants;
    • the Financial Creditors; and
    • the SIHPL Market Purchase Claimants,
    who are envisaged to be settled in accordance with the terms of the SIHPL Section 155 Proposal.
  4. The SIHPL Section 155 Proposal shall be put to a vote at a virtual meeting or meetings, convened for such purpose.
  5. The SIHPL Section 155 Proposal does not constitute, on any basis whatsoever, an admission of any liability on the part of SIHPL towards any party that has instituted legal proceedings against SIHPL, or intends to institute such legal proceedings or has threatened to institute such legal proceedings or who may assert a claim of whatsoever nature and howsoever arising, in legal proceedings.

If you are a SIHPL MPC Claimant or a SIHNV MPC Claimant, you may be entitled to participate in the SoP Settlement Fund (as set out in the Proposals (as applicable)). This means that you:

  1. held or purchased Steinhoff Shares at any time before 5 December 2017 c.o.b.; and
  2. continued to hold such shares until (at least) 5 December 2017 c.o.b..

If you meet these conditions, please carefully read the following instructions and sign and submit this Claim Form, as you may be entitled to participate in the SoP Settlement Fund as set out in the Proposals.

If anything in this Claim Form or the Proposals is unclear, please refer to the Frequently Asked Questions on the website: www.steinhoffsettlement.com.

Further information including the Proposals (which Proposals include all relevant definitions) and other documents can be found at www.steinhoffsettlement.com. Additionally, the SIHNV Composition Plan is available for inspection at the court registry of the District Court of Amsterdam.

1.1 DO NOT SUBMIT A CLAIM FORM IF YOU ARE REPRESENTED BY A CLAIMANT REPRESENTATIVE

If you are represented by a Claimant Representative, before submitting a Claim Form please verify with your Claimant Representative whether they will submit (or have submitted) a Claim on your behalf. If so, you should NOT submit a Claim Form. You will not receive double compensation for one and the same claim(s). We will ask you to confirm this again in Part 5 of this Claim Form.

1.2 Do not submit a Claim Form if you do not have a Claim

To the extent you do not have a Claim eligible for compensation, please do NOT submit a Claim Form. False, non-existent and fraudulent Claims may be reported to the relevant authorities.

1.3 Timely submission of the Claim Form including documents

Please ensure that you have submitted your completed Claim Form along with the required documentation by no later than the Bar Date. Failure to submit the Claim Form on time may lead to the rejection of your Claim, which means you will not receive any compensation for your Claim.

1.4 Claim Determination by SRF

Pursuant to the Proposals, MPC Claimants need to submit their Claims to the Claims Administrator in order to receive compensation (if any) under those Proposals.

Submission of this Claim Form does not mean that you will receive compensation under the Proposals. Eligibility for compensation will initially be reviewed by the Claims Administrator and conclusively determined by SRF in accordance with the Proposals (as applicable).

1.5 Filing in respect of the Proposals

The completed Claim Form will be used to determine whether you qualify as a SIHPL MPC Claimant (in which case you may be eligible to submit your Claims for compensation against SIHPL in the Section 155 Proceedings) and/or an SIHNV MPC Claimant (in which case you may be eligible to submit your Claims for compensation against SIHNV in the SoP Proceedings). Please refer to the Proposals for the relevant provisions: www.steinhoffsettlement.com.

In brief:

  1. you potentially qualify as a SIHPL MPC Claimant if you purchased SIHPL Shares in the period prior to 6 December 2015; and
  2. you potentially qualify as an SIHNV MPC Claimant if you purchased SIHNV Shares in the period from 7 December 2015 up to 5 December 2017 c.o.b.,
  3. provided that you continued to hold such shares (in the case of SIHPL Shares, those subsequently converted to SIHNV Shares pursuant to the Scheme of Arrangement) until (at least) 5 December 2017 c.o.b.

1.6 Based on the completed Claim Form your Claim will be submitted in the relevant proceedings if they are filed before the relevant deadlines

The Claims Administrator will file your SIHPL MPC Relevant Claims in the Section 155 Proceedings on the basis of the SIHPL Filing Instruction in Part 9.B of this Claim Form. You may also elect whether you wish to attend the virtual Section 155 Meeting personally and vote at that meeting or appoint a proxy to attend and vote on your behalf.

By submitting the SIHNV Filing Instruction in Part 9.B of this Claim Form, your SIHNV MPC Relevant Claims are filed with the Claims Administrator in the SoP Proceedings. This Claim Form does not entitle you to vote in respect of your SIHNV MPC Relevant Claims. Instead, the SoP Administrator can request the District Court of Amsterdam to appoint a SoP Committee of Representatives to vote in respect of the SIHNV Composition Plan, instead of individual creditors.

For further details we refer to Part 9.B of this Claim Form.

1.7 Rejection of Claims if supporting evidence is not sufficient or defects are not remedied

You will not be entitled to any compensation and your MPC Relevant Claim(s) may be rejected if you do not submit your Claims with sufficient supporting information and documentary evidence on or before the Bar Date and/or do not timely remedy any defects (which will be notified by the Claims Administrator).

For these purposes, supporting information and documentary evidence shall not be sufficient if it is incomplete or incorrect in any material respect, as determined by the Claims Administrator and/or the SRF.

1.8 No double compensation for the same Claim

You cannot recover as both an SIHNV MPC Claimant and an SIHPL MPC Claimant, or vice versa, if such recoveries would result in more than one payment for the same MPC Relevant Claim.

1.9 Submission online; confirmation

Once you have completed your Claim Form, please sign in the space provided at the end of the Claim Form and submit the Claim Form accompanied with copies of all the supporting documentation by clicking "Submit".

You will receive an automatically generated confirmation of your submission once completed. If you do not receive such confirmation, please contact the Claims Administrator using the contact details provided below.

1.10 Submission by post

In the event you cannot submit your Claim Form online, the Claims Administrator can accept submission by (only) regular mail. If you file a Claim Form by postal services, you accept and agree that you bear any risk related thereto (including, but not limited to, the risk that the submission is received after any applicable deadline). Please contact the Claims Administrator using the contact details immediately below for further details:

Email: info@steinhoffsettlement.com

Toll-free US number: +1 866-559-7591

UIFN toll-free International number: +49 (0) 800-2667-8831

Toll-free South Africa number: +27 (0) 860 024 737

Lines are open weekdays between 8am and 4:30pm SAST.

1.11 Any questions?

You will find further information, including the Proposals and all relevant definitions and documents at the case website www.steinhoffsettlement.com.

If you have any questions about this Claim Form, please take a look at our frequently asked questions page or contact the Claims Administrator directly at info@steinhoffsettlement.com.

Part 4. Expected timetable of the key events

Below you will find the relevant dates in respect of the SoP Proceedings and the Section 155 Proceedings. Please bear these dates in mind when completing your Claim Form. These dates can be subject to change.

The Claim Form must be submitted on or before the Bar Date.

SoP Proceedings

Event Time and/or date
Voting Record Date15 June 2021
Voting Hearing10.00 a.m. (CET) on 30 June 2021
Settlement Effective Date The date on which the "Conditions Precedent" (as defined in the SIHNV Composition Plan) and all "Suspensive Conditions" (as defined in the SIHPL Section 155 Proposal) are fulfilled, such date to be published by way of a press release on SIHNV’s website
Bar DateThe date falling three months after the Settlement Effective Date, calculated from the Settlement Effective Date
Payment As soon as reasonably practicable after the Bar Date once all MPC Claimants have been notified of their Claim Determination and the Claim Determinations (that are not disputed) have become final

Section 155 Proceedings

Event Time and/or date
Deadline for submission of the Claim Form if you wish to attend and vote at the Section 155 Meeting (Note: you will still be entitled to submit a Claim Form after this date, but only for purposes of receiving payment) 05 May 2021
Deadline for submission of SIHPL Filing InstructionTo be announced on www.steinhoffsettlement.com
Section 155 MeetingTo be announced on www.steinhoffsettlement.com
Settlement Effective Date The date on which the "Conditions Precedent" (as defined in the SIHNV Composition Plan) and all "Suspensive Conditions" (as defined in the SIHPL Section 155 Proposal) are fulfilled, such date to be published by way of a press release on SIHNV’s website
Bar DateThe date falling three months after the Settlement Effective Date, calculated from the Settlement Effective Date
Payment As soon as reasonably practicable after the Bar Date once all MPC Claimants have been notified of their Claim Determination and the Claim Determinations (that are not disputed) have become final

Part 5. Are you represented by a Claimant Representative?

Are you represented by a Claimant Representative?

This means that you have registered with or joined one of the following Claimant Representatives in relation to your MPC Relevant Claim:

  • Burford Capital Holdings (UK) Limited / Burford Capital LLC
  • Deminor Recovery Services (Luxembourg) S.à.r.l. (currently Deminor Recovery Services (Luxembourg) SA) / DRS Belgium S.C.R.L (currently DRS Belgium SRL);
  • Grant & Eisenhofer P.A., / Kessler Topaz Meltzer & Check, LLP / bureau Brandeis B.V.; or
  • The International Steinhoff Litigation Group (DRRT Inc., DRRT Limited, Tilp Rechtsanwaltgesellschaft MBH, LHL Attorneys Inc., Stichting Steinhoff International Compensation Claims, Birkway B.V. or Bynkershoek B.V.).
Yes      No

Before completing this Claim Form, please verify with your Claimant Representative whether they will submit (or have submitted) your Claim on your behalf.

If yes: you should not submit a Claim Form yourself. You will not receive double compensation for one and the same claim(s).

If no: Please proceed and complete the rest of the Claim Form.

Part 6.A. Claimant Identification: guidance

Details to be provided

Please use this Part 6 of the Claim Form to list the MPC Claimant’s name, mailing address, and relevant account information.

If your claimant identification information changes, please immediately notify SRF c/o the Claims Administrator in writing via info@steinhoffsettlement.com.

For assignees only

If you were not the party who originally purchased the Steinhoff Shares, but received MPC Relevant Claims through transfer or assignment, you must provide details and documentary evidence (i.e. the assignment agreement) of that assignment. On the basis of that information, the Claims Administrator can review your Claim and check, for example, that the Claim has been validly assigned and the Claim has not been submitted by the assignor as well.

Part 6.B. Claimant Identification

South African Resident for exchange control purposes (see Authorised Dealer Manual if in doubt)
Yes      No


If you received the Claims via transfer or assignment by another party:

If you received this Claim via transfer or assignment by another party, you MUST submit proof of valid assignment of the Claim. Please upload acceptable proof here:

Click the "Browse" or "Choose File" button and select the relevant file from your computer. The selected files will be uploaded when the "Agree and Submit" button is clicked.

Required documentation may be uploaded in .jpg,.jpeg,.tif,.tiff,.gif,.png,.pdf format only. You may upload up to 10 files. A single file cannot be larger than 30 MB.

Identity documents

Please upload the following identity document(s) below, as applicable:

  1. For natural persons (i.e. individuals): photocopy of your identity book/card or passport;
  2. For corporate entities: photocopies of registration/incorporation documents
  3. For trusts: photocopies of the trust deed and the letters of authority of trustees

Click the "Browse" or "Choose File" button and select the relevant file from your computer. The selected files will be uploaded when the "Agree and Submit" button is clicked.

Required documentation may be uploaded in .jpg,.jpeg,.tif,.tiff,.gif,.png,.pdf format only. You may upload up to 10 files. A single file cannot be larger than 30 MB.

 

Part 7.A. Transactions in Steinhoff Shares: guidance

Purpose of this section

Please use this Part 7 of this Claim Form entitled "Transactions in Steinhoff Shares" to supply all required details of your purchases, sales and relevant holdings of Steinhoff Shares and the relevant dates thereof. Failure to report all such information may result in the rejection of your Claim in whole or in part.

Required Transaction Information and Supporting Evidence

Please provide all of the requested information with respect to all of your relevant transactions and holdings of Steinhoff Shares. If any of the requested documents or information are not in your possession, please obtain a certified copy or equivalent documents from the relevant broker because these documents are necessary to prove and process your Claim. Failure to provide this documentation could delay review of your Claim or result in rejection of your Claim in whole or in part.

Please submit with this Claim Form reliable evidence, as well as related supporting documentation for transactions and/or holdings of Steinhoff Shares (in electronic format) including, but not limited to:

  1. bank or brokerage statements from a third-party financial institution that include the claimant’s name, account number, shareholdings and transactional history and printed on their letterhead or accompanied by a written and duly signed declaration of the bank or broker;
  2. records of transactions from a third-party bank and/or broker that include claimant name, account number, shareholdings and transactional history and printed on their letterhead or accompanied by a written and duly signed declaration of the bank or broker;
  3. certificates issued by Steinhoff Group Companies for shares it administered that include claimant name, account number and shareholdings, to the extent that the share remains certificated and has not been dematerialised;
  4. print-screens of a claimant’s shareholdings and transactions history that have been signed by a bank/broker and printed on their letterhead or accompanied by a written and duly signed declaration of the bank or broker; or
  5. a written and duly signed declaration from a third-party entity which (i) is regulated and audited and (ii) has credible systems to maintain and keep trading data as business records confirming the shareholdings and transactional history, that includes: claimant name, account number and shareholdings and transactional history, provided that the Claims Administrator may require additional documentation to support the declaration and confirm the authenticity of the respective transactions.

The following supporting documentation will in any event not be considered reliable evidence of the existence of a Claim by an MPC Claimant: (i) print-screens of a claimant’s shareholdings and/or transactional history that have not been signed by a bank and printed on their letterhead or are not accompanied by a written and duly signed declaration of the bank or broker; (ii) (sworn) statements, affidavits, self-generated reports and hand-written reports drafted by individual retail claimants themselves; and (iii) self-generated tax related documents.

For more information on the required documentation we refer to Schedule 2 of the SRF and Claims Administration Conditions (Required Claim Information) available at: www.steinhoffsettlement.com.

The Claims Administrator may request such additional information and/or documentation as it deems necessary and appropriate. SRF may provide guidance in respect of the necessary evidentiary documentation.

Determination by SRF

SRF, upon advice of the Claims Administrator, will determine whether and to what extent you are entitled to compensation for your claim, based upon information and documentary evidence submitted through this Claim Form to the Claims Administrator. This determination will be made by SRF in accordance with the Proposals (including the Steinhoff Allocation Plan and the SRF and Claims Administration Conditions), as approved and confirmed by the relevant courts. The Proposals, the Steinhoff Allocation Plan and the SRF and Claims Administration Conditions can be found here: www.steinhoffsettlement.com.

Part 7.B. Transactions in Steinhoff Shares

You must provide the information requested below on your holdings of Steinhoff Shares. Before completing this Part, please consider the Steinhoff Allocation Plan carefully for guidance on which transaction types are relevant for the purposes of your Claim.

Beginning Holdings Number of Steinhoff shares owned at the close of business on 1 March 2009:
End Holdings Number of Steinhoff shares held at the close of business on 5 December 2017:

You must submit proof of your End Holding.

You must submit proof of your End Holding. Acceptable proof includes a bank or brokerage statement from a third-party financial institution that shows your name, account number and End Holding and which is printed on the bank/broker’s letterhead or accompanied by a written and duly signed declaration of the bank or broker. Self-generated documents will not be accepted. If you are unable to provide any evidence of your End Holding, you will not qualify as an MPC Claimant.

Click the "Browse" or "Choose File" button and select the relevant file from your computer. The selected files will be uploaded when the "Agree and Submit" button is clicked.

Required documentation may be uploaded in .jpg,.jpeg,.tif,.tiff,.gif,.png,.pdf format only. You may upload up to 10 files. A single file cannot be larger than 30 MB.


Transactions. Please provide details of all purchases, sales, transfers and bond conversions of Steinhoff Shares made during the period from the opening of business on 2 March 2009 through to the close of business on 6 December 2017 . You must provide details of all transactions during this period.

  Cents .
                  
  Cents .
                                                
   Yes      No

Yes      No

Yes      No

You must submit proof of all transactions in Steinhoff shares.

You must submit proof of all transactions in Steinhoff shares listed above which includes brokerage and trade statements that include your name, account number, trade date, number of shares and price per share. Beginning holdings of Steinhoff shares can be confirmed with monthly holding statements. Self-generated documents will not be accepted.

Click the "Browse" or "Choose File" button and select the relevant file from your computer. The selected files will be uploaded when the "Agree and Submit" button is clicked.

Required documentation may be uploaded in .jpg,.jpeg,.tif,.tiff,.gif,.png,.pdf format only. You may upload up to 10 files. A single file cannot be larger than 30 MB.

 

Part 8.A. Compensation Payment Information: guidance

In the event SRF finally determined that you are eligible to receive compensation for your Claim, you will receive the payment of the compensation after the Bar Date. The payment will be transferred to your bank account (in respect of a cash payment) or securities account (in respect of a payment in shares, if applicable) in accordance with the details provided by you in this Part 8. Such details should be provided in accordance with the SRF and Claims Administration Conditions. As set out in the Terms and Conditions, you bear the risk that the payment / account details are incorrect. You can only provide one bank account and one securities account (meaning also one account for Claimants that are joint owners or beneficiaries of a Claim).

Please note that payments by SRF (if any) will be made in Euro (EUR) or South African Rand (ZAR), in accordance with the Proposals (as applicable). If you are: (i) entitled to receive a cash payment in ZAR; and (ii) a South African resident, your ZAR cash payment can be made only into a South African bank account.

IMPORTANT NOTE TO OVERSEAS MPC CLAIMANTS

THE PPH SHARES (AS DEFINED BELOW) HAVE NOT BEEN, AND WILL NOT BE, REGISTERED UNDER THE US SECURITIES ACT OF 1933, AS AMENDED (THE "SECURITIES ACT") OR UNDER THE RELEVANT SECURITIES LAWS OF ANY STATE OR TERRITORY OR OTHER JURISDICTION OF THE UNITED STATES AND WILL NOT BE LISTED ON ANY STOCK EXCHANGE IN THE UNITED STATES. THE PPH SHARES ARE EXPECTED TO BE DISTRIBUTED TO MPC CLAIMANTS IN THE UNITED STATES IN RELIANCE UPON THE EXEMPTION FROM THE REGISTRATION REQUIREMENTS OF THE SECURITIES ACT PROVIDED BY SECTION 3(A)(10) THEREOF, OR PURSUANT TO ANOTHER EXEMPTION FROM, OR IN A TRANSACTION NOT SUBJECT TO, THE REGISTRATION REQUIREMENTS OF THE SECURITIES ACT.

OTHER OVERSEAS MPC CLAIMANTS SHOULD CONSULT THEIR INDEPENDENT PROFESSIONAL ADVISERS AS TO WHETHER THEY REQUIRE ANY GOVERNMENTAL OR OTHER CONSENTS OR NEED TO OBSERVE ANY OTHER FORMALITIES TO ENABLE THEM TO RECEIVE THE PPH SHARES TO WHICH THEY ARE ENTITLED UNDER THE PROPOSALS. IF AN MPC CLAIMANT IS IN ANY DOUBT AS TO HIS OR HER ELIGIBILITY TO RECEIVE PPH SHARES THEY SHOULD CONTACT THEIR INDEPENDENT PROFESSIONAL ADVISER IMMEDIATELY.

Part 8.B. Compensation Payment Information

Payment in cash

PLEASE NOTE THAT YOU SHOULD PROVIDE DETAILS OF A SOUTH AFRICAN BANK ACCOUNT TO THE EXTENT YOU ARE A SOUTH AFRICAN RESIDENT AND ARE ENTITLED TO RECEIVE A PAYMENT IN ZAR.

Select one:            
(applicable to South African, US and UK/Irish banks)

Payment in shares

PLEASE NOTE THAT THE PPH SHARES CAN ONLY BE TRANSFERRED DIRECTLY TO THE MPC CLAIMANT OR TO A NOMINEE REGISTERED WITH STRATE PROPRIETARY LIMITED.

Please indicate whether you are eligible to receive shares in Pepkor Holdings Limited ("PPH Shares").

You (the MPC Claimant) will be "ineligible" to receive PPH Shares if each of the following conditions is met: (i) you are not a natural person; (ii) you previously exclusively held SIHNV Shares listed on the Frankfurt Stock Exchange; and (iii) your internal rules or regulations prohibit you from owning Johannesburg Stock Exchange listed shares, and such rules have been in place since prior to 27 July 2020 (i.e. you are a "Qualifying Ineligible Claimant").

Please note that, if you click "No, I am not eligible to receive PPH Shares" below (and only in that situation), the final determination as to your eligibility will be made by the SRF, upon the advice of the Claims Administrator. You will be notified of this decision in the Claim Determination.

Options

Yes, I am eligible to receive PPH Shares
No, I am not eligible to receive PPH Shares because I am a Qualifying Ineligible Claimant (as defined above)

If you answered "No" to the above, please provide documentary evidence of the internal rules or regulations which prohibit the ownership of PPH Shares below, in the form of a sworn affidavit (or equivalent) attaching a certified copy of the applicable rules or regulations.

By clicking "No" to the above and provided that you are a Qualifying Ineligible Claimant, you acknowledge and agree that:

  1. instead of receiving the PPH Shares to which you may be entitled, the relevant number of PPH Shares will be sold by SRF (in consultation with SIHNV and SIHPL) on the secondary market and the proceeds of such sale minus any and all costs will be transferred to your bank account in accordance with the details provided by you in this Part 8;
  2. SRF is authorised to, and shall, sell such PPH Shares at any time, even if the quoted value of the PPH Shares at JSE is less than ZAR 15 per PPH Share; and
  3. the costs and any and all risks in connection with such sale by SRF of the PPH Shares on the secondary market are for your account, including the risks relating to the price and execution of such sale.

Click the "Browse" or "Choose File" button and select the relevant file from your computer. The selected files will be uploaded when the "Agree and Submit" button is clicked.

Required documentation may be uploaded in .jpg,.jpeg,.tif,.tiff,.gif,.png,.pdf format only. You may upload up to 10 files. A single file cannot be larger than 30 MB.

If you answered "Yes" to the above, please indicate whether you have a South African Central Securities Depository ("CSD") participant or brokers account and, if so, please provide the relevant account details below.

Yes, I have a South African CSD participant or brokers account (please provide relevant details below)
No, I do not have a South African CSD participant or brokers account

If you answered "No" to the above, a securities account will be opened for you with the Computershare Central Securities Depository Participant ("CSDP") by default. This will enable you to receive your allotted PPH Shares. However, please note that you will not be permitted to trade (i.e. sell or transfer) in such PPH Shares until you have provided all relevant documentation requested by the CSDP. Upon allocation of the PPH Shares, the CSDP will communicate with you via the email address provided in this Claim Form in order to obtain the required documentation. If you do not provide the documentation requested by the CSDP, you may not be able to trade your PPH Share entitlement, nor will you be entitled to receive a greater portion of your settlement consideration in cash.

By clicking "No", you are deemed to have:

  1. read and agreed to Computershare’s Terms and Conditions, available here;
  2. consented to being contacted by the CSDP for the purposes of completing the relevant formalities; and
  3. (for institutional investors only) acknowledged and agreed that there may be a fee associated with the opening of an account on your behalf, which will be borne solely by you.

(For institutional investors only) If you answered "No, I do not have a securities account" to the above, please specify the contact name and telephone number of the broker that you wish to appoint:

Note: if you are a retail investor, Computershare will appoint a broker on your behalf by default.

Any and all risks relating to the correctness and accuracy of the indication provided by you on whether or not you are eligible and (if applicable) whether or not you have a South African CSD participant or brokers account, and any and all risks relating to you otherwise not timely and/or fully complying with this Part 8, are for your account.

 

Part 9.A. Filing instructions: guidance

SoP proceedings

This Part is only relevant to SIHNV MPC Claimants.

If you are an SIHNV MPC Claimant, you are invited to file your SIHNV MPC Relevant Claim.

If you submit this Claim Form to the Claims Administrator on or before the Voting Record Date (15 June 2021) you file such SIHNV MPC Relevant Claim(s) in the SoP. If the Voting Record Date has passed, your SIHNV MPC Relevant Claim(s) may still be admitted in the SoP:

  1. until two days before the Voting Hearing, if you so request at the Voting Hearing and neither the SoP Administrator nor – in the event of a meeting in accordance with Section 255(1)(2°) DBA – any of the other attending creditors object; or
  2. at the Voting Hearing, if you reside outside of the European part of the Netherlands and provided that you were unable to file your SIHNV MPC Relevant Claim(s) earlier.

By submitting this Claim Form, your SIHNV MPC Relevant Claim will be filed for the Claim Value as initially determined (for the purposes of the SoP Proceedings only) by the Claims Administrator. Alternatively, you may indicate to file your SIHNV MPC Relevant Claim for a different amount. Please note however that:

  1. the SoP Administrator will contest ("betwisten") all SIHNV MPC Relevant Claims that are filed for an amount that differs from the Claim Value as initially determined (for the purposes of the SoP Proceedings only) by the Claims Administrator in accordance with the Valuation Principles; and
  2. the SoP Administrator will propose the supervisory judges in the SoP Proceedings to admit all SIHNV MPC Relevant Claims for an amount that equals the Claim Value as initially determined (for the purposes of the SoP Proceedings only) by the Claims Administrator in accordance with the Valuation Principles.

Please note that the SoP Administrator will request the District Court of Amsterdam to appoint a SoP Committee of Representatives. If appointed by the District Court of Amsterdam, the SoP Committee of Representatives, instead of individual creditors of SIHNV, will vote on the SIHNV Composition Plan. This Claim Form therefore does not entitle or invite you to cast a vote on the SIHNV Composition Plan. The SoP Committee of Representatives (if appointed) will be exclusively entitled to vote on the SIHNV Composition Plan. You can find further information on the appointment and composition of the SoP Committee of Representatives (when available) online at: www.steinhoffsettlement.com.

This filing is also referred to as the "SIHNV Filing Instruction".

Section 155 Proceedings

This Part is only relevant to SIHPL MPC Claimants.

The SIHPL Section 155 Proposal will be put to a vote at a virtual Section 155 Meeting. If you qualify as a SIHPL MPC Claimant, you may be eligible to cast your vote in respect of the SIHPL Section 155 Proposal at the virtual Section 155 Meeting.

If (i) you submit this Claim Form to the Claims Administrator on or prior to the date stipulated therefor, which date shall be published on www.steinhoffsettlement.com and (ii) the Claims Administrator initially determines that you qualify as a SIHPL MPC Claimant, you also instruct the Claims Administrator to incorporate the SIHPL MPC Relevant Claim(s) in the report to be submitted by the Claims Administrator to the chairperson of the virtual Section 155 Meeting for admission in the Section 155 Proposal. This will be referred to as the "SIHPL Filing Instruction".

In the SIHPL Filing Instruction, you can elect whether you wish to attend the virtual Section 155 Meeting personally and vote at that Meeting or to appoint a proxy (such as the chairperson of the virtual Section 155 Meeting) to attend the virtual Section 155 Meeting and vote on your behalf. If you choose to provide a proxy to the chairperson, you must instruct the chairperson to vote either in favour of or against the SIHPL Section 155 Proposal (or abstain from voting) on your behalf. This voting proxy can be revoked prior to the Section 155 Meeting.

If you do not fill out the voting proxy but do wish to give a proxy to someone else to vote on your behalf at the virtual Section 155 Meeting, you can still submit a separate proxy until 72 hours prior to the Section 155 Meeting. Please contact the Claims Administrator for more information in this case.

If you do not wish to instruct the chairperson of the virtual Section 155 Meeting or a third party to vote on your behalf, you may participate in the virtual Section 155 Meeting yourself. In this case, SIHPL and/or the Claims Administrator on its behalf will send you an invite to participate in the virtual Section 155 Meeting to vote in respect of the SIHPL Section 155 Proposal.

You can find further information on how to participate in the virtual Section 155 Meeting at: www.steinhoffsettlement.com.

Part 9.B. The Filing Instructions

Please note that this part only applies to the extent you filed your SIHNV MPC Relevant Claims before 15 June 2021 and/or your SIHPL MPC Relevant Claims before the deadline for submission of the Claim Form if you wish to attend and vote at the Section 155 Meeting, which date shall be published on www.steinhoffsettlement.com.

  1. By (electronically) signing and submitting this Claim Form, I (we) submit my (our) Claims with the Claims Administrator in respect of SIHNV MPC Relevant Claims and the chairperson of the virtual Section 155 Meeting in respect of SIHPL MPC Relevant Claims, and:

SIHNV Filing Instruction:

  1. To the extent that, as determined after the initial review of the Claims Administrator, I (we) qualify as an SIHNV MPC Claimant with respect to the purchase of SIHNV Shares between 7 December 2015 o.o.b. and 5 December 2017 c.o.b., I (we):
    1. file our SIHNV MPC Relevant Claim(s) (i.e. the claims relating to the purchase of shares between 7 December 2015 o.o.b. and 5 December 2017 c.o.b.) with the Claims Administrator in the SoP, for:
      1. the Claim Value as initially determined (for the purposes of the SoP Proceedings only) by the Claims Administrator in accordance with the Valuation Principles; or
      2. the following amount in EUR:
    2. instruct the Claims Administrator to do all such things concerning the respective SIHNV MPC Relevant Claim(s) that the Claims Administrator may deem necessary in respect of the above actions; and

SIHPL Filing Instruction:

  1. To the extent, as determined after the initial review of the Claims Administrator, I (we) qualify as a SIHPL MPC Claimant with respect to the purchase of SIHPL Shares in the period prior to 6 December 2015 c.o.b.:
    1. appoint and instruct the Claims Administrator to incorporate my (our) SIHPL MPC Relevant Claim(s) (i.e. the claims relating to the purchase of shares prior to 6 December 2015 c.o.b.) in the report to be submitted by the Claims Administrator to the chairperson of the virtual Section 155 Meeting for admission in the Section 155 Proposal, for the Claim Value as initially determined (for the purposes of the Section 155 Meeting only) by the Claims Administrator in accordance with the Valuation Principles, and take all necessary actions in relation thereto.

IF YOU DO NOT WISH TO APPOINT A PROXY, PLEASE SELECT ‘NO PROXY’

  1. I (we) appoint and instruct:
    1. the chairperson of the virtual Section 155 Meeting;
    2. a third party, namely:
    3. no proxy

ONLY IF YOU ELECTED TO PROVIDE A PROXY TO THE CHAIRPERSON, SELECT ONE OF THE FOLLOWING CHOICES, OTHERWISE YOU OR THE ELECTED THIRD PARTY ON YOUR BEHALF CAN PARTICIPATE IN THE SECTION 155 MEETING

to do any of the following actions at the virtual Section 155 Meeting on my (our) behalf:

  1. vote IN FAVOUR of the SIHPL Section 155 Proposal on the basis of such SIHPL MPC Relevant Claim(s) (i.e. the claims relating to the purchase of shares prior to 6 December 2015 c.o.b.) filed with the Claims Administrator;
  2. vote AGAINST the SIHPL Section 155 Proposal on the basis of such SIHPL MPC Relevant Claim(s) (i.e. the claims relating to the purchase of shares prior to 6 December 2015 c.o.b.) filed with the Claims Administrator; or
  3. ABSTAIN from voting with respect to the SIHPL Section 155 Proposal on the basis of such SIHPL MPC Relevant Claim(s) (i.e. the claims relating to the purchase of shares prior to 6 December 2015 c.o.b.) filed with the Claims Administrator,

and to do all such things concerning the respective claim(s) that it may deem necessary in respect of the above actions.

Conditions of the Filing Instructions

By providing this SIHNV Filing Instruction and the SIHPL Filing Instruction to the Claims Administrator, as applicable, I (we):

  1. accept that I am (we are) bound by such SIHNV Filing Instruction and SIHPL Filing Instruction, as applicable;

  2. to the extent a voting proxy is provided, accept that the party appointed may exercise the voting actions stipulated by the proxy with respect to the then current version of the SIHPL Section 155 Proposal, including in the event the SIHPL Section 155 Proposal is amended before the virtual Section 155 Meeting, to the extent the voting proxy has not been revoked;

  3. only to the extent I (we) qualify as an SIHNV MPC Claimant with respect to the purchase of SIHNV Shares between 7 December 2015 o.o.b. and 5 December 2017 c.o.b., as established after the initial review of the Claims Administrator:
    1. accept that if the SoP Committee of Representatives is appointed by the District Court of Amsterdam I (we) will not be entitled to vote with respect to the SIHNV Composition Plan and that instead the SoP Committee of Representatives if so appointed by the District Court of Amsterdam will be entitled to vote with respect to the SIHNV Composition Plan;

    2. accept that the Claims Administrator will initially determine the Claim Value of the SIHNV MPC Relevant Claims in accordance with the Valuation Principles only for the purpose of admission in the SoP;

    3. accept that if I (we) indicate an amount of my (our) SIHNV MPC Relevant Claims for a different amount than initially determined (for the purposes of the SoP Proceedings only) by the Claims Administrator, the SoP Administrator will contest my (our) SIHNV MPC Relevant Claims at the Voting Hearing; and

    4. authorise the Claims Administrator to disclose full details of the name, full legal entity name (if applicable) and all other relevant information required to submit my (our) SIHNV MPC Relevant Claim(s) in the SoP, and to the extent necessary, to the SoP Administrator, the supervisory judges in the SoP and the District Court of Amsterdam.

  4. only to the extent I (we) only to the extent I (we) qualify as a SIHPL MPC Claimant with respect to the purchase of SIHPL Shares in the period prior to 6 December 2015 c.o.b., as established after the initial review of the Claims Administrator:
    1. accept that the Claim Value of the SIHPL MPC Relevant Claims will be determined in accordance with the Valuation Principles only for the purposes of the Claims Administrator executing the SIHPL Filing Instruction; and

    2. authorise the Claims Administrator to disclose full details of the name, full legal entity name (if applicable) and all other relevant information required in order to submit the SIHPL MPC Relevant Claim(s) to the chairperson of the virtual Section 155 Meeting,

    3. and, to the extent the voting proxy is provided:
    1. accept that you will be represented at the virtual Section 155 Meeting by proxy granted to the party appointed in the voting proxy;
    2. accept that the party appointed in the voting proxy will cast the votes at the virtual Section 155 Meeting in respect of the SIHPL Section 155 Proposal by proxy on behalf of your SIHPL MPC Relevant Claims; and
  5. agree and acknowledge that the SIHNV Filing Instruction and the SIHPL Filing Instruction, as applicable, are governed by the laws of the Netherlands.

Part 10.A. Representations: guidance

In order for the Claims Administrator and SRF to be able to accurately assess your Claim and to rely on the information submitted by you, you need to make certain representations and warranties as set out in this Part 10.

Part 10.B. Representations

By signing and submitting this Claim Form, I (we) make the following representations and warranties to SRF and the Claims Administrator on the date of this Claim Form in each case by reference to the facts and circumstances existing on such date. Each of the following representations and warranties are made on your behalf:

  1. (in the case of natural persons) I (we) have full legal capacity (in Dutch: "handelingsbekwaam"), have been declared of age and otherwise have full contractual capacity in respect of the execution of this Claim Form and have not been (i) placed under curatorship or tutelage (as applicable) (in Dutch: "onder curatele gesteld"), (ii) granted suspension of payments (in Dutch: "surseance verleend") or declared bankrupt (in Dutch: "failliet verklaard") or insolvent and am (are) not subject to a debt rescheduling (in Dutch: "schuldsanering natuurlijke personen WSNP") or (iii) subjected to any analogous proceedings in any jurisdiction and the administration over my (our) assets has not been entrusted to another person (in Dutch: "onder bewind gesteld");
  2. (in the case of legal persons) it is duly incorporated (if a corporate person) or duly established (in any other case) and validly existing under the law of its jurisdiction of incorporation or formation;
  3. (in the case of legal persons) it has not had its assets placed under administration (in Dutch: "onderbewind gesteld") and has not been (i) dissolved (in Dutch: "ontbonden"), merged (in Dutch: "gefuseerd") or split up (in Dutch: "gesplitst"), (ii) subjected to any prevention, intervention and resolution measures (including the preparation of a transfer plan) under the Financial Supervision Act (in Dutch: "Wet op het financieel toezicht") (iii) subjected to any one of the insolvency proceedings listed in Annex A to Regulation (EU) 2015/848 on insolvency proceedings (recast) or any insolvency proceedings under the Insolvency Act 24 of 1936 as read with the Companies Act 71 of 2008 and Chapter XIV if the Companies Act 61 of 1973 or any analogous proceedings in any jurisdiction, including bankruptcy (in Dutch: "faillissement") and moratorium (in Dutch: "surseance van betaling") or (iv) liquidated (whether provisionally or finally) or deregistered or placed under business rescue or any analogous proceedings;
  4. the obligations expressed to be assumed by me (us) in terms of this Claim Form are legal, valid, binding and enforceable;
  5. the entry into and performance by me (us ) of this Claim Form and the transactions contemplated under it do not and will not conflict with any law or regulation applicable to my (our) constitutional documents (if applicable);
  6. I (we) have the power to enter into, perform and deliver, and have taken all necessary action to authorise the entry into, performance and delivery of this Claim Form and the transactions contemplated by this Claim Form and the Proposals and such authorisation is valid, complete and in full force and effect as of the date of this Claim Form;
  7. all authorisations required for the performance by me (us) of this Claim Form and the transactions contemplated under it have been obtained or effected and are in full force and effect;
  8. I (we) have not entered into any side agreements with any Released Party (as defined in the SIHNV Composition Plan) or related third party, other than set out in the Annex to this Claim Form;
  9. the Claims in relation to which I (we) are submitting this Claim Form are not encumbered (including, but not limited to, by any claim, charge, mortgage, lien, restriction, assignment, option, equitable right, power of sale, pledge, hypothecation, security interest, usufruct, retention of title, right of pre-emption, right of first refusal or other third party right or security interest of any kind or an agreement, arrangement or obligation to create any of the foregoing), and there is no attachment levied on those Claims, in such way that I (we) cannot (or an assignor, if applicable, could not) freely make use of my (our) Claim(s) as envisaged in this Claim Form;
  10. beyond those accounts identified in this Claim Form, I (we) do not own any accounts in the same capacity containing Steinhoff Shares that would entitle me (us) to participate in the SoP Settlement Fund and, to the extent I (we) do own multiple accounts in the same capacity containing such Steinhoff Shares, I (we) have aggregated my (our) Claims in respect of such accounts into one Claim Form; and
  11. the statements made in this Claim Form and the documents accompanying it are complete, true and accurate.

Part 11.A. Releases: guidance

The persons that are entitled to receive a compensation for their claims under the Proposals, in return must provide a full and final release and waiver of claims against Steinhoff, its group companies, its directors and officers (in respect of claims related to matters after 5 December 2017) and its advisers (in respect of claims related to matters after 5 December 2017). Please seek legal advice if you are uncertain what such release and waiver entails.

Part 11.B. Releases Steinhoff

1 Definitions

2 Waivers and releases to Steinhoff, D&Os and advisers of Steinhoff

I (we) agree to fully, finally and irrevocably release (verlenen finale kwijting) on a several basis and waive any and all of their rights in connection with:

2.1 any and all Claims it may have against SIHNV, SIHPL and any other Steinhoff Group Company in respect of all matters relating (directly or indirectly) to the Events and/or the Allegations, such releases to be effective as of the date of receipt by SRF, alternatively by SRF taking control, of the Gross Settlement Fund;

2.2 any and all actual and/or potential direct and/or indirect, contractual and non-contractual (including statutory) Claims it may have against any D&Os in relation to any matters, facts and circumstances that occurred after 5 December 2017, save for fraud and gross misconduct, such releases to be effective as of the date of receipt by SRF of the D&O Settlement Funds; and

2.3 any and all actual and/or potential direct and/or indirect, contractual and non-contractual (including statutory) Claims it may have against advisers retained by any Steinhoff Group Company and their personnel, offices, partners and directors in relation to any matters, facts and circumstances that occurred after 5 December 2017, save for fraud and gross misconduct, such releases to be effective as of the date of receipt by SRF, alternatively by SRF taking control, of the Gross Settlement Fund.

Part 11.A. Submission to Jurisdiction: guidance

The submission of this Claim Form requires you to agree to the jurisdiction of the Dispute Committee in the event of any disputes in respect of your claim. You can find the Dispute Committee Rules here: www.steinhoffsettlement.com.

Please note that the Proposals and the SRF and Claims Administration Conditions each have their own jurisdiction and governing law clauses. You can find these documents here: www.steinhoffsettlement.com. You are also required to explicitly agree to submit your relevant Claims to the jurisdiction of those forums.

Part 11.B. Submission to Jurisdiction

Inquiries of the Claims Administrator and the Dispute Committee

By submitting this Claim Form, I (we) agree to be subject to inquiry by the Claims Administrator and, if applicable, the Dispute Committee with respect to the eligibility, validity and/or amount of the claim(s) for compensation made in this Claim Form. This includes providing all documentation requested by the Claims Administrator and as required in the performance of its duties.

Jurisdiction; choice of forum

By signing and submitting this Claim Form, I agree:

  1. in accordance with clause 6.6.1 of the SRF and Claims Administration Conditions and with paragraph 2.1 of the regulations of the Dispute Committee set out in Schedule 5 (Dispute Committee Rules) of the SRF and Claims Administration Conditions, which are published on www.steinhoffsettlement.com, to submit to the exclusive jurisdiction of the Dispute Committee to resolve by way of binding advice (in Dutch: "bindend advies") under article 7:900 et seq. of the Dutch Civil Code and agree to the exclusive applicability of Dutch law in respect thereof: all matters and disputes between SRF, a Settlement Creditor (including an MPC Claimant) and/or a Respondent (including SIHNV and SIHPL) (as defined in the SRF and Claims Administration Conditions) in relation to the question whether and to which extent the MPC Claimant is entitled to compensation pursuant to the SRF Settlement Documents (as defined in the SRF and Claims Administration Conditions) (including the Claim Determination), as well as the matters and disputes relating to duplicate claims set out in clause 6.4.5(iii) of the SRF and Claims Administration Conditions;
  2. to the extent I (we) am (are) an SIHNV MPC Claimant only, in accordance with Clause 16 of the SIHNV Composition Plan, to submit to the exclusive jurisdiction of the Netherlands Arbitration Institute ("NAI") to resolve the following disputes by arbitration in accordance with the NAI Arbitration Rules: any disputes exclusively arising out of or in connection with the SIHNV Composition Plan, including disputes concerning its existence, its validity and any non-contractual obligations, to the extent such disputes do not fall under the jurisdiction of (i) the Dispute Committee; or (ii) the competent court in respect of a request to set aside (in Dutch: "ontbinden") the SIHNV Composition Plan within the meaning of Section 280(1) in conjunction with Section 165 DBA;
  3. to the extent I (we) am (are) a SIHPL MPC Claimant only, in accordance with Clause 46.2 of the SIHPL Section 155 Proposal, to submit to the non-exclusive jurisdiction of the High Court of South Africa, Western Cape Division, Cape Town, with respect to any disputes arising out of or in connection with the SIHPL Section 155 Proposal (other than disputes referred to the Dispute Committee as set out above);
  4. in accordance with Clause 8.2 of the SRF and Claims Administration Conditions, to submit to the exclusive jurisdiction of the NAI, to resolve the following disputes by arbitration in accordance with the NAI Arbitration Rules: any disputes arising out of or in connection with the SRF and Claims Administration Conditions, including disputes concerning the existence and validity thereof, but excluding disputes where the Dispute Committee has exclusive jurisdiction; and
  5. in accordance with Clause 8.3 of the SRF and Claims Administration Conditions, to submit to the exclusive jurisdiction of the Amsterdam District Court (and its appellate courts), or, to the extent it involves a dispute in my (our) capacity as SIHPL MPC Claimant, the High Court of South Africa, Western Cape Division, Cape Town, regarding summary proceedings in respect of any disputes arising out of or in connection with the SRF and Claims Administration Conditions; and
  6. in accordance with paragraph 2.4 of the Dispute Committee Rules, in relation to any dispute or procedure in connection with and/or further to the Dispute Committee Rules and any dispute settled or anticipated to be settled on the basis of the Dispute Committee Rules the Amsterdam District Court (the Netherlands) shall have exclusive jurisdiction, unless you are a national of or established in South Africa, in which case the High Court of South Africa, Western Cape Division, Cape Town shall have exclusive jurisdiction.

Part 12. Processing of Personal Data

  1. Steinhoff International Holdings N.V. ("SIHNV"), a company incorporated under the laws of the Netherlands, registered with the Dutch Trade Register under number 63570173, and with its registered address at Building B2, Vineyard Office Park, corner of Adam Tas and Devon Valley Road, Stellenbosch, Western Cape, South Africa, and
  2. Steinhoff International Holdings (Pty) Ltd ("SIHPL"), a company incorporated under the laws of South Africa, registered under number 1998/003951/07, and with its principal place of business at Building B2, Vineyard Office Park, corner of Adam Tas and Devon Valley Road, Stellenbosch, Western Cape, South Africa,

    both acting as joint controllers,

have appointed the Claims Administrator for the processing of the personal data (i.e. any information relating to you as an identified or identifiable individual) that you include in this Claim Form for the purpose of the Steinhoff Group Settlement to which you want to participate (the "Personal Data").

As from the date on which the SIHNV Composition Plan and the SIHPL Section 155 Proposal will become effective (the "Settlement Effective Date"), the Stichting Steinhoff Recovery Foundation (SRF) , a foundation (to be) incorporated under the laws of the Netherlands and registered with the Dutch trade register, acting as (independent) controller, will take over from SIHNV and SIHPL and become controller of the processing of the Personal Data by the Claims Administrator while SIHNV and/or SIHPL will continue processing the Personal Data solely to the extent necessary in the context of the (execution and implementation of the) Steinhoff Group Settlement.

The Personal Data will be processed as referred to above in accordance with the EU General Regulation on Data Protection (2016/679) (the "GDPR") and the Dutch GDPR Implementation Act (Uitvoeringswet Algemene Verordening gegevensbescherming) as well as Section 14 of the Constitution of South Africa and the South African Protection of Personal Information Act 4 of 2013 and the Regulations Relating to the Protection of Personal Information, 2018 – GN R1383/2018 and the UK Data Protection Act 2018 and any other relevant data protection legislation as may be applicable (jointly the "Data Protection Regulations").

Purposes and legal basis of the processing of the Personal Data

SIHNV and SIHPL jointly until the Settlement Effective Date and SRF thereafter will process the Personal Data for the purposes of administering, assessing and settling your Claim in the context of the Settlement Fund (as defined in the SRF and Claims Administration Conditions).

Such processing of the Personal Data shall take place pursuant to the legitimate interests of SIHNV and SIHPL as well as of SRF after the Settlement Effective Date, as a legal basis, such legitimate interest being to execute and implement the terms of the SIHNV Composition Plan and the SIHPL Section 155 Proposal as required by the District Court of Amsterdam, the High Court of South Africa, Western Division, Cape Town, as well as any other relevant jurisdictions (as applicable), including to determine whether to dispute or defend a Claim Determination with the Dispute Committee. Such legitimate interest has been assessed in consideration of your own interests and fundamental rights. The provision of the Personal Data is required to enable you to participate in the Settlement Funds. Failure to provide the Personal Data will prevent you from participating.

In no case will the processing of the Personal Data entail any (solely) automated decision-making.

Recipients of the Personal Data

The Personal Data will be shared with the following categories of recipients for the above purposes, on a need to know basis in the context of the Steinhoff Group Settlement:

  1. third parties advising and assisting SIHNV and SIHPL as well as SRF, such as accountants, bailiffs, lawyers and notaries;
  2. the Claims Administrator;
  3. entities of the Claims Administrator’s group, including outside the European Union;
  4. sub-processors of the Claims Administrator;
  5. the SoP Administrator, the Supervisory Judges, the SoP Committee of Representatives and the chair of the voting meeting of the SIHPL Section 155 Proposal;
  6. the Dispute Committee;
  7. the Deloitte Firms and the D&O Insurers; and
  8. any national and/or international regulatory or enforcement body or court provided we are legally required to share the Personal Data or decide to do so as part of our legal defence.

As the case may be, the above recipients may act as controllers or processors. In the latter case, the processors may only process the Personal Data on behalf of SIHNV, SIHPL and (after the Settlement Effective Date) SRF based on their instructions and must comply with specific contractual obligations SIHNV, SIHPL and/or SRF are imposing on them for the protection of the Personal Data in accordance with the Data Protection Regulations.

Some of the above recipients are located in a country outside the European Economic Area which is not considered adequate from a data protection viewpoint by the EU Commission (such as the USA and South Africa). In that case, appropriate safeguards shall be implemented, such as the relevant Standard Contractual Clauses adopted by the EU Commission. You can obtain a copy of these clauses upon request using the communications referred to below.

Retention of the Personal Data

The Personal Data shall be retained as long as necessary for the administration of your Claim or as long as required by law. It shall be destroyed or anonymised shortly thereafter.

Your rights

You may exercise the following rights under the conditions and within the limits set forth in the Data Protection Regulations:

  1. the right to access the Personal Data as processed by SIHNV, SIHPL and SRF and, if you consider that any Personal Data is incorrect, obsolete or incomplete, to request its correction or updating;
  2. the right to request the erasure of the Personal Data or the restriction of its processing;
  3. the right to object, in whole or in part, to the processing of your Personal Data; and
  4. the right to request the portability of the Personal Data, i.e. that it be returned to you or transferred to the entity of your choice, in a structured, commonly used and machine-readable format and subject to confidentiality obligations.

In addition to the above rights, if you consider that we have not processed your Personal Data in accordance with the Data Protection Regulations, you have the right to file a complaint with the competent data protection authority(ies).

Contact us

If you have any question about the processing of the Personal Data or want to exercise any of the above rights, please contact the Claims Administrator via info@steinhoffsettlement.com.

Part 13. Documentary requirements for representatives only

Are you filing this Claim Form in a representative capacity?

Yes I am filing the Claim Form in a representative capacity
No I am filing the Claim Form on my own behalf

You may skip this part.



To the extent you act in a representative capacity:

Valid authorisation to submit the Claim Form

You must provide documentary proof that the MPC Claimant(s) you purport to represent has (have) validly authorised you to (amongst others) submit their MPC Relevant Claims in the SoP Proceedings and/or the Section 155 Proceedings.

Valid authorisation to collect the distributions

To the extent the MPC Claimant(s) you purport to represent has (have) authorised you or another third party to collect the payments that they are entitled to on their behalf, you must provide documentary proof of such (valid) authorisation.

Valid authorisation to submit the Filing Instruction

You must provide proof that the MPC Claimant(s) that you purport to represent has (have) validly authorised you to provide the SIHNV Filing Instruction and/or SIHPL Filing Instruction to the Claims Administrator, to the extent applicable.

Please upload evidence of your valid authority to act on behalf of the MPC Claimant here:

Click the "Browse" or "Choose File" button and select the relevant file from your computer. The selected files will be uploaded when the "Agree and Submit" button is clicked.

Required documentation may be uploaded in .jpg,.jpeg,.tif,.tiff,.gif,.png,.pdf format only. You may upload up to 10 files. A single file cannot be larger than 30 MB.

Valid signature of the authorisations

Please answer the following questions:

  1. Is (are) the person (or persons) that authorised you to file the MPC Relevant Claims a legal entity?
    Yes      No
    If yes, you must provide proof that such legal entity is validly represented by the signatory of the authorisation.
  2. Is (are) the person (or persons) that authorised you to submit the SIHNV Filing Instruction and/or SIHPL Filing Instruction a legal entity?
    Yes      No
    If yes, you must provide proof that such legal entity is validly represented by the signatory of the authorisation.
  3. Are you filing claims on behalf of MPC Claimants that are joint account holders, co-beneficiaries and co-owners?
    Yes      No
    If yes, you must provide proof that all joint account holders validly authorised you to file the claim and execute this Claim Form and submit the SIHNV Filing Instruction and/or SIHPL Filing Instruction on their behalf.

Click the "Browse" or "Choose File" button and select the relevant file from your computer. The selected files will be uploaded when the "Agree and Submit" button is clicked.

Required documentation may be uploaded in .jpg,.jpeg,.tif,.tiff,.gif,.png,.pdf format only. You may upload up to 10 files. A single file cannot be larger than 30 MB.

Part 14. Signature

YOU MUST ELECTRONICALLY SIGN THIS CLAIM FORM ON THIS PAGE. SUBMISSION OF THE CLAIM FORM MEANS SUBMISSION TO THE CLAIMS ADMINISTRATOR.

FAILURE TO SIGN WILL RESULT IN A REJECTION OF YOUR CLAIM.

IF YOU ARE FILING AS OR ON BEHALF OF A JOINT ACCOUNT HOLDER, THE CLAIM FORM MUST BE SIGNED BY OR ON BEHALF OF ALL ACCOUNT HOLDERS. PLEASE CLICK "+" TO ADD ADDITIONAL SIGNATURES.

Your typed name will serve as your electronic signature.

Please state your representative capacity (for representatives only).








Annex

Settlement Agreement Deloitte, D&O and D&O Insurers

Guidance

The D&O Insurers (also on behalf of the Insured Persons, as defined in the SSSA) and the Deloitte Firms have agreed to offer additional compensation to MPC Claimants in respect of their Claims relating to the Events and/or the Allegations. Their offers are hereafter referred to as the D&O Insurers Market Purchase Claimants Offer and the Deloitte Market Purchase Claimants Offer. Under the terms of these offers, MPC Claimants may be eligible to receive a payment pursuant to these offers in addition to compensation under the Steinhoff settlement. To be eligible for this additional compensation under the D&O Insurers Market Purchase Claimants Offer and the Deloitte Market Purchase Claimants Offer you must confirm your acceptance in accordance with the instructions and terms below. For completeness sake, in return for the additional compensation you agree to the full, final and irrevocable releases and waivers of rights as set out in the following section.

Therefore, the following section will ask you to confirm whether you accept the D&O Insurers Market Purchase Claimants Offer and/or the Deloitte Market Purchase Claimants Offer and agree to the releases and waivers of rights. Acceptance of the respective offers by ticking the acceptance boxes in the following sections also means acceptance of the conditions as set out therein.

If you do NOT wish to accept the offers, please only tick the non-acceptance box at the end of the following section. In that case, you will NOT be eligible to receive a payment of additional compensation under the D&O Insurers Market Purchase Claimants Offer and the Deloitte Market Purchase Claimants Offer.

Please make sure that you have received independent legal advice about the risks of and the legal merits and the reasonableness of the D&O Insurers Market Purchase Claimants Offer and the Deloitte Market Purchase Claimants Offer.

Annex

Settlement Deloitte, D&O and D&O Insurers

1 Introduction

1.1 Capitalised terms used but not defined in this Annex have the meaning given to them in the Proposals.

1.2 In a press release dated 27 July 2020, Steinhoff announced its global settlement offer. The settlement consideration as proposed by Steinhoff thereunder was stated to be independent from recoveries that claimants may make from other sources and that such recoveries (if any) will be in addition to the settlement consideration proposed by Steinhoff.

1.3 Since then:

  1. the Deloitte Firms have made a settlement offer to all MPC Claimants (the "Deloitte Market Purchase Claimants Offer"). The terms of the Deloitte Market Purchase Claimants Offer can be found here; and
  2. the D&O Insurers (also on behalf of certain Insured Persons) have made a settlement offer to all MPC Claimants (the "D&O Insurers Market Purchase Claimants Offer"). The terms of the D&O Insurers Market Purchase Claimants Offer can be found here.

1.4 Participation in either the Deloitte Market Purchase Claimants Offer or the D&O Insurers Market Purchase Claimants Offer is NOT a requirement for either eligibility:

  1. to vote in the Voting Hearing on the SIHNV Composition Plan or the SIHPL Section 155 Proposal; or
  2. for payment from the SoP Settlement Fund under the SIHNV Composition Plan or the SIHPL Section 155 Proposal.

1.5 This means that any payments pursuant to the Deloitte Market Purchase Claimants Offer and the D&O Insurers Market Purchase Claimants Offer are in addition to any payments to which you may be entitled under the SIHNV Composition Plan and/or the SIHPL Section 155 Proposal (as applicable).

1.6 As recorded below, the acceptance by the MPC Claimants of the D&O Insurers Market Purchase Claimants Offer (the "D&O Insurers Agreement") and acceptance of the Deloitte Market Purchase Claimants Offer (the "Deloitte Agreement" and, together with the D&O Insurers Agreement, the "Agreements") through this Claim Form is intended to acknowledge (and as the case may be perfect) the waivers and releases to the D&O Beneficiaries, the Deloitte Beneficiaries and the (other) Audit Firms that are included in Clause 12 of the SIHNV Composition Plan (as amended) and/or Clause 27.16 of the SIHPL Section 155 Proposal (as amended) to the extent they are not already binding by operation of law. The confirmations contained herein shall not impair or diminish any of the binding nature of the waivers and releases in Clause 12 of the SIHNV Composition Plan and/or Clause 27.16 of the SIHPL Section 155 Proposal whether by operation of law or otherwise.

1.7 I (we) agree that the Claims Administrator is hereby authorised to disclose a copy of this Annex to the Deloitte Firms and the D&O Insurers.

2 Agreement with the D&O Insurers Market Purchase Claimants Offer

2.1 I (we) irrevocably accept the D&O Insurers Market Purchase Claimants Offer.

2.2 I (we) agree and acknowledge that acceptance of the D&O Insurers Market Purchase Claimants Offer means that I (we) may be eligible to receive compensation from the D&O Insurers Market Purchase Claimants Offer, and in return I (we) agree to the waivers and releases in the following paragraphs which I (we) accept will be legally binding and effective in respect of all my (our) Claims including those that the SRF ultimately determines are not accepted for any compensation in accordance with the terms of the D&O Insurers Market Purchase Claimants Offer and the SRF and Claims Administration Conditions.

3 Full, final and irrevocable discharge and release of D&O Beneficiaries

3.1 Subject to the occurrence of the Settlement Effective Date and receipt by SRF of the D&O Insurers Market Purchase Claimants Offer and D&O Steinhoff Additional Support Offer (as defined in the SSSA), as of the Settlement Effective Date, I (we) fully, finally, irrevocably and on a several basis:

  1. waive any and all of my (our) rights and Claims in any jurisdiction against any D&O Beneficiaries; and
  2. release (verlenen finale kwijting) the D&O Beneficiaries from any Liability in respect of:
    1. any matters, whether known or unknown, related to or in connection with (directly or indirectly) the Events and/or the Allegations;
    2. in relation to any matters, facts and circumstances, directly or indirectly, whether known or unknown, that have occurred after 5 December 2017, save for fraud and misconduct.

3.2 By providing the waiver and release set out in para. 3.1, I (we) (a) acknowledge that the boards of SIHNV and SIHPL have determined that the terms of the Steinhoff Group Settlement taken together with the SSSA are in the best interests of SIHNV and SIHPL and other Steinhoff Group Companies and the Scheme Creditors (as defined in the SIHPL Section 155 Proposal) and the SoP Creditors (as defined in the SIHNV Composition Plan), (b) confirm that I (we) are in agreement with and do not and shall not dispute such determination and (c) confirm that the terms of the Steinhoff Group Settlement together with the SSSA, the D&O Insurers Market Purchase Claimants Offer and the Deloitte Market Purchase Claimants Offer adequately compensate me (us) for my (our) Claims.

3.3 Subject to the occurrence of the Settlement Effective Date and receipt by SRF of the D&O Insurers Market Purchase Claimants Offer and D&O Steinhoff Additional Support Offer, I (we) will not demand under Section 165 of the South African Companies Act, or otherwise under any equivalent legislation, that SIHNV or any Steinhoff Group Company (initiate or continue to) pursue any Claims that SIHNV or any Steinhoff Group Company may have or in the future may have in respect of any matters arising out of, relating to or in connection with (directly or indirectly whether known or unknown) the Events and/or the Allegations against any D&O Beneficiaries and that any such demand made before the Settlement Effective Date, if any, shall be withdrawn as of the Settlement Effective Date.

3.4 I (we) agree to immediately suspend and hold in abeyance and, subject to the occurrence of the Settlement Effective Date and receipt by SRF of the D&O Insurers Market Purchase Claimants Offer and D&O Steinhoff Additional Support Offer, on the Settlement Effective Date to terminate forthwith any pending legal proceedings (of whatsoever nature, and howsoever arising) against any of the D&O Beneficiaries relating to the Events and/or Allegations or any Claim waived and/or any Liability released pursuant hereto, with each party to such proceedings bearing its own costs, and not to recommence and/or re-institute any such legal proceedings nor to commence any new legal proceedings (of whatsoever nature, and howsoever arising) relating to any Claim waived and/or any Liability released pursuant hereto.

Options:

I (we) accept the D&O Insurers Market Purchase Claimants Offer.
I (we) DO NOT accept the D&O Insurers Market Purchase Claimants Offer.

4 Agreement with the Deloitte Market Purchase Claimants Offer

4.1 I (we) irrevocably accept the Deloitte Market Purchase Claimants Offer.

4.2 I (we) agree and acknowledge that acceptance of the Deloitte Market Purchase Claimants Offer means that I (we) may be eligible to receive compensation from the Deloitte Market Purchase Claimants Offer, and in return I (we) agree to the waivers and releases in the following paragraphs which I (we) accept will be legally binding and effective in respect of all my (our) Claims including those that the SRF ultimately determines are not accepted for any compensation in accordance with the Deloitte Market Purchase Claimants Offer and the SRF and Claims Administration Conditions.

5 Full, final and irrevocable discharge and release of the Deloitte Beneficiaries and the (other) Audit Firms

5.1 Subject to the occurrence of the Settlement Effective Date and receipt by SRF of the Deloitte Market Purchase Claimants Offer and the Deloitte Steinhoff Additional Support Offer (as defined in the SSSA), as of the Settlement Effective Date, I (we) fully, finally, irrevocably and on a several basis:

  1. waive any and all of my (our) rights and Claims in any jurisdiction against any Deloitte Beneficiary and (other) Audit Firm; and
  2. release (verlenen finale kwijting) the Deloitte Beneficiaries and the (other) Audit Firms from any Liability,
in respect of any matters, whether known or unknown, related to or in connection with (directly or indirectly) the Events and/or the Allegations.

5.2 By providing the waiver and release set out in para. 5.1, I (we) (a) acknowledge that the boards of SIHNV and SIHPL have determined that the terms of the Steinhoff Group Settlement taken together with the SSSA are in the best interests of SIHNV and SIHPL and other Steinhoff Group Companies and the Scheme Creditors and the SoP Creditors, (b) confirm that I (we) are in agreement with and do not and shall not dispute such determination and (c) confirm that the terms of the Steinhoff Group Settlement together with the SSSA, the D&O Insurers Market Purchase Claimants Offer and the Deloitte Market Purchase Claimants Offer adequately compensates me (us) for my (our) Claims.

5.3 Subject to the occurrence of the Settlement Effective Date and receipt by SRF of the Deloitte Market Purchase Claimants Offer and the Deloitte Steinhoff Additional Support Offer, I (we) will not demand under Section 165 of the South African Companies Act, or otherwise under any equivalent legislation, that SIHNV or any Steinhoff Group Company (initiate or continue to) pursue any Claims that SIHNV or any Steinhoff Group Company may have or in the future may have in respect of any matters arising out of, relating to or in connection with (directly or indirectly, whether known or unknown) the Events and/or the Allegations against any Deloitte Beneficiary and (other) Audit Firm and that any such demand made before the Settlement Effective Date, if any, shall be withdrawn as of the Settlement Effective Date.

5.4 I (we) agree to immediately suspend and hold in abeyance and, subject to the occurrence of the Settlement Effective Date and receipt by SRF of the Deloitte Market Purchase Claimants Offer and the Deloitte Steinhoff Additional Support Offer, on the Settlement Effective Date to terminate forthwith any pending legal proceedings (of whatsoever nature, and howsoever arising) against any of the Deloitte Beneficiaries and the (other) Audit Firms relating to the Events and/or Allegations or any Claim waived and/or any Liability released pursuant hereto, with each party to such proceedings bearing its own costs, and not to recommence and/or re-institute any such legal proceedings nor to commence any new legal proceedings (of whatsoever nature, and howsoever arising) or complaint relating to any Claim waived and/or any Liability released pursuant hereto.

Options:

I (we) accept the Deloitte Market Purchase Claimants Offer.
I (we) DO NOT accept the Deloitte Market Purchase Claimants Offer.

6 Limitation of liability

None of the D&O Beneficiaries or the Deloitte Beneficiaries and the (other) Audit Firms or their respective counsel shall have any role in, responsibility for, or liability with respect to the implementation of the Steinhoff Allocation Plan, the form, substance, method or manner of distribution, the administration or distribution of the SoP Settlement Fund, the D&O Insurers Market Purchase Claimants Offer and/or the Deloitte Market Purchase Claimants Offer, any tax liability that an MPC Claimant may incur as a result of the SRF and Claims Administration Conditions, the SIHNV Composition Plan and/or the SIHPL Section 155 Proposal or as a result of any action taken pursuant to the SRF and Claims Administration Conditions, the SIHNV Composition Plan and/or the SIHPL Section 155 Proposal, or the administration or processing of Claims, including, without limitation, the determination of the amounts to be distributed to each MPC Claimant or the determination of the validity of a submitted Claim for payment from the SoP Settlement Fund, the D&O Insurers Market Purchase Claimants Offer and/or the Deloitte Market Purchase Claimants Offer.

7 Third-party stipulation

This Annex contains irrevocable third-party stipulations (in Dutch: onherroepelijk derdenbeding) within the meaning of section 6:253 of the Dutch Civil Code in respect of the D&O Beneficiaries and the Deloitte Beneficiaries and the (other) Audit Firms. To the extent acceptance of such third-party stipulations is required, the receipt by SRF of the D&O Insurers Market Purchase Claimants Offer shall be deemed to constitute such acceptance by the D&O Beneficiaries and the receipt by SRF of the Deloitte Market Purchase Claimants Offer shall be deemed to constitute such acceptance by the Deloitte Beneficiaries and the (other) Audit Firms.

8 Governing law and dispute resolution

8.1 For the purpose of this Clause, I (we) acknowledge that the D&O Beneficiaries and the Deloitte Firms fall under the definition of a Respondent and the MPC Claimants fall under the definition of a Settlement Creditor, both as defined in the SRF and Claims Administration Conditions.

8.2 I (we) agree that this Annex, including the Agreements, and any (non-contractual) obligations arising out of or in connection with it shall be governed and construed exclusively in accordance with Dutch law.

8.3 I (we) agree:

  • 8.3.1 to submit to the exclusive jurisdiction of the Netherlands Arbitration Institute ("NAI") to resolve the following disputes by arbitration in accordance with the NAI Arbitration Rules: any disputes concerning the existence, validity and any non-contractual obligations arising out of or in connection with the Agreements;
  • 8.3.2 in accordance with clause 6.6.1 of the SRF and Claims Administration Conditions and with paragraph 2.1 of the regulations of the Dispute Committee set out in Schedule 5 (Dispute Committee Rules) of the SRF and Claims Administration Conditions, which are published on www.steinhoffsettlement.com, to submit to the exclusive jurisdiction of the Dispute Committee to resolve by way of binding advice (in Dutch: "bindend advies") under article 7:900 et seq. of the Dutch Civil Code and agree to the exclusive applicability of Dutch law in respect thereof, all matters and disputes between SRF, a Settlement Creditor and/or a Respondent in relation to the question whether and to which extent the MPC Claimant is entitled to compensation pursuant to the SRF Settlement Documents (as defined in the SRF and Claims Administration Conditions) (including the Claim Determination), as well as the matters and disputes relating to duplicate claims set out in clause 6.4.5(iii) of the SRF and Claims Administration Conditions;
  • 8.3.3 in accordance with Clause 8.2 of the SRF and Claims Administration Conditions, to submit to the exclusive jurisdiction of the NAI, to resolve the following disputes by arbitration in accordance with the NAI Arbitration Rules: any disputes arising out of or in connection with the SRF and Claims Administration Conditions, including disputes concerning the existence and validity thereof, but excluding disputes where the Dispute Committee has exclusive jurisdiction; and
  • 8.3.4 in accordance with Clause 8.3 of the SRF and Claims Administration Conditions, to submit to the exclusive jurisdiction of the Amsterdam District Court (and its appellate courts), or, to the extent it involves a dispute with a Settlement Creditor in its capacity as a SIHPL MPC Claimant, the High Court of South Africa, Western Cape Division, Cape Town, regarding summary proceedings in respect of any disputes arising out of or in connection with the SRF and Claims Administration Conditions; and
  • 8.3.5 in accordance with paragraph 2.4 of the Dispute Committee Rules, in relation to any dispute or procedure in connection with and/or further to the Dispute Committee Rules and any dispute settled or anticipated to be settled on the basis of the Dispute Committee Rules the Amsterdam District Court (the Netherlands) shall have exclusive jurisdiction, unless the Settlement Creditor (including an MPC Claimant) is a national of or established in South Africa, in which case the High Court of South Africa, Western Cape Division, Cape Town shall have exclusive jurisdiction.

ACCURATE CLAIMS PROCESSING TAKES A SIGNIFICANT AMOUNT OF TIME. THANK YOU FOR YOUR PATIENCE.

Loading…