Form 55 (Rules 73-78) Proof Of Debt/general Form Page 2

(a) State consideration as goods and services sold and delivered by me to the company

between the dates of

Please attach copies of all original claim documents and certificates.

All attached documents and claims must be stamped by the Commissioner of Affidavits.

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Particulars of Account referred to on the other side

Date

Consideration

Amount

Remarks.

The Vouchers (if any) by which the account

can be substantiated should be set out here

______________________________

Deponent’s Signature

_________________________________

Signature of Commissioner of Affidavits

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Parent category: Legal