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 ON BEHALF OF EMPLOYEES

To the liquidator of Limited

I (full name of person making the statement) of (full address) being (occupation) state:

1. the company was, on (date of court order in winding up, if winding up was by the Court, or date of resolution to wind up if a voluntary winding up), and still is, indebted to the persons whose names, addresses and descriptions appear in Columns 2, 3 and 4 in the Schedule;

2. the debt is for wages, salaries, annual leave, retrenchment payments or long service leave, due to them for services rendered while employed by the company during the periods set out in Column 5 against the names of the persons;

3. the debt of the company due to each person is for the amount set out in Column 6 against the name of that person;

4. none of those persons has had or received any satisfaction or security in respect of that debt;

5. I am authorised as and the source of my information is as follows: