Corporations Regulations 2001

(subregulation 5.6.49(2)

A.C.N or A.R.B.N:

Corporations Act 2001

FORMAL PROOF OF DEBT OR CLAIM (GENERAL FORM)

To the liquidator of Limited

1. This is to state that the company was on (date of court order in winding up by the Court, or date of resolution to wind up, if a voluntary winding up), and still is, justly and truly indebted to (full name and address of the creditor and, if applicable, the creditor’s partners. If prepared by an employee or agent of the creditor, also insert a description of the occupation of the creditor) for

dollars and cents

Particulars of the debt are:

2. To my knowledge or belief the creditor has not, nor has any person by the creditor’s order, had or received any satisfaction or security for the sum or any part of it except for the following: (insert particulars of all securities held. If the securities are on the property of the company, assess the value of those securities. If any bills or other negotiable securities are held, show them in a schedule in the following form).

*3. I am employed by the creditor and authorised in writing by the creditor to make this statement. I know that the debt was incurred for the consideration stated and that the debt, to the best of my knowledge and belief, remains unpaid and unsatisfied.

*3. I am the creditor’s agent authorised in writing to make this statement in writing. I know the debt was incurred for the consideration stated and that the debt, to the best of my knowledge and belief, remains unpaid and unsatisfied.

Dated

Signature

Occupation

Address

*Do not complete if this proof is made by the creditor personally