Form 55 (Rules 73-78) Proof Of Debt/general Form

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FORM 55
(Rules 73-78)
Proof of Debt/General Form
(Title same as in Form 2)
I, ___________________________________________________________________________
(Name and Occupation of deponent)
of __________________________________________________________________________
(Address of deponent)
make oath and say:
That I am a creditor of CLICO INVESTMENT BANK LIMITED, that I am authorized to make
this affidavit, and that it is within my own knowledge that the debt hereinafter deposed to was
incurred and for the consideration stated, and that such debt, to the best of my knowledge and
belief still remains unpaid and unsatisfied.
That the above named Company was, at October 17, 2011, and still is truly indebted to me
______________________ in the sum of $____________ for (a) __________________________
as shown by the account endorsed hereon, ___________________________________________
________________________________________________________________for which sum or
any part thereof I say that I have not had or received any manner of satisfaction.
Sworn at _________________ )
)
_________________________ )
)
______________________________
this _______ day of _________ )
Deponent’s Signature
)
__________________________ )
)
20______________________
)
Before me ___________________________________
____________________________________________
Signature of Commissioner of Affidavits

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