Employee Proof Of Claim printable pdf download

Employee Proof Of Claim

EMPLOYEE PROOF OF CLAIM

In the matter of the Bankruptcy of Pareto Corporation and Pareto Holdings Ltd (the "Debtor") and the

claim of ______________________________

(Name)

All notices or correspondence regarding this claim to be sent to the creditor at the following

address:___________________________________________________________________________

City: ____________________ Province: ____________________ Post Code: ____________________

Phone: __________________ Fax: ________________________ E-mail: _______________________

I, __________________________________, residing in the City of ________________________, in

(Name)

the Province of ____________________, do certify that:

1) I am a creditor of the Debtor in my capacity as a former employee of the Debtor.

2) I have the knowledge of all circumstances connected with the claim referred to below.

3) The Debtor was, as at the date of bankruptcy, namely the 2

day of October, 2013, and is still

indebted to me in the sum of CAD$____________________ in respect of unpaid wages, vacation

pay, severance, or termination pay, as follows:

Wages owing CAD$

_________________

Vacation pay CAD$

_________________

Termination pay CAD$ _________________

Severance pay CAD$

_________________

Other: CAD$

_________________

*If necessary, attach supporting calculations in respect

the above and attach to this Proof

Claim as Schedule

Dated at ________________________, this _____ day of ___________, 2013.

___________________________________________________

________________________________________________

(Signature of individual completing the form)

(Signature of witness)

The completed Employee Proof of Claim should be returned to:

KPMG Inc. - Trustee

Attention: Asya Rzhevsky

333 Bay Street – Suite 4600

Toronto ON M5H 2S5

Employee Proof Of Claim