Proof of debt - general form
1 Insolvent company
2 Date of insolvency *
3 Name of creditor
(If a company please also give company registration
4 Address of creditor for correspondence
5 Total amount of claim, including any VAT and
outstanding uncapitalised interest as at the date
the company entered insolvency.
Where payment is made or set-off applied
after the date of insolvency this should
be deducted and relevant deductions disclosed.
6 Details of any documents by reference to
which the debt can be substantiated.
There is no need to attach them but the insolvency
practitioner may call for any document or
evidence to substantiate the claim at his discretion
as may the chairman or convenor of any meeting).
7 If the amount in 5 above included outstanding
uncapitalised interest please state the amount.
8 Particulars of how and when the debt incurred (If
you need more space append a continuation
sheet to this form).
9 Particulars of any security held, the value of the
security, and the date it was given.
10 Particulars of any reservation of title claimed in
respect of the goods supplied to which the claim
11 Signature of creditor or person authorised to act
on his behalf.
Name in BLOCK LETTERS
Position with or relation to creditor
Address of person signing (if different from 2
* Please note that where the company is in liquidation following an administration, the relevant date for claims is the
date the company entered administration and not the date it moved to liquidation, i.e. the date of the first insolvency