Proof Of Claim Form - Republic Of Trinidad And Tobago
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1
2REPUBLIC OF TRINIDAD AND TOBAGO
The Bankruptcy and Insolvency Act, 2007
FORM 12
(Sections 27, 32(1)(e)(i), 71(1), 73(1)(d), 93(3), 100, 115 of the Act and Regulations 18, 20, 52 and 97)
________________________________________________________________________
PROOF OF CLAIM
All notices or correspondence regarding this claim must be forwarded to the following address:
______________________________________________________________________________
______________________________________________________________________________
In the matter of the bankruptcy (or the proposal or the receivership) of _______________________
(name
of
debtor)
of
____________________(city
and
province)
and
the
claim
of
_____________________________, creditor.
I, ____________________________________ (name of creditor or representative of the creditor), of
________________________ (city and province), do hereby certify:
1.
That I am a creditor of the above-named debtor (or that I am __________________ (state position or
title) of ___________________ (name of creditor or representative of the creditor)).
2.
That I have knowledge of all of the circumstances connected with the claim referred to below.
3.
That the debtor was, at the date of bankruptcy (or the date of the receivership or, in the case of a
proposal, the date of the notice of intention or of the proposal, if no notice of intention was filed),
namely the ______ day of ____________ ____, and still is, indebted to the creditor in the sum of
$____________, as specified in the statement of account (or affidavit) attached and marked Schedule
“A,” after deducting any counterclaims to which the debtor is entitled. (The attached statement of
account or affidavit must specify the vouchers or other evidence in support of the claim.)
4.
Check and complete appropriate category
☐ A. UNSECURED CLAIM OF $____________.
That in respect of this debt, I do not hold any assets of the debtor as security and
(Check appropriate description)
Regarding the amount of $_______, I claim a right to a priority under section 127 of the
☐
Act.
Regarding the amount of $_______, I do not claim a right to a priority.
☐
(Set out on an attached sheet details to support priority claim)
☐ B. SECURED CLAIM OF $_____________.
That in respect of this debt, I hold assets of the debtor valued at $______ as security, particulars of
which are as follows:
(Give full particulars of the security, including the date on which the security was given and the
value at which you assess the security, and attach a copy of the security documents)
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