Proof Of Debt - General Form


Rule 14.4
Proof of debt - general form
In the matter of Example Limited – in Administration
Date of administration – 8 April 2017
You MUST insert the name of the creditor here.
1 Name of creditor
IF the creditor is a company or limited liability partnership, insert the full legal
entity name and the company registered number.
(If a company please also give company registration
IF you are an individual (e.g. a former employee), insert your name.
You MUST insert the address of the creditor here.
2 Address of creditor for correspondence
IF the creditor is a company or limited liability partnership, insert the normal
address for correspondence.
IF you are an individual (e.g. a former employee), insert your address.
3 Email address
Please provide an email address that can be used for any correspondence.
Enter the total amount owed to you as at the appointment date, including the
4 Total amount of claim, including any VAT and
outstanding uncapitalised interest as at the date
You must include any VAT and uncapitalised interest.
the company went into administration.
Uncapitalised interest is any interest due on your debt up to the date of insolvency
which is not principal debt. You can only claim interest if you are entitled to it
Where payment is made or set-off applied after
under a written contract or legal agreement, or if you demanded it in writing prior
to the date of insolvency and made it clear that interest would be charged from the
the date of administration, this should be
date of the demand.
deducted and relevant deductions disclosed.
You should supply copies of the agreement or demand under which you are
claiming interest.
You must then deduct from this figure any amounts paid to you since the date of
the appointment in relation to the total claim. This does not include payments made
5 Details of any documents by reference to which
for any orders placed by the Joint Administrators.
You must also deduct any amounts in relation to set-off.
the debt can be substantiated. (Note: There is no
Ensure all deductions are clearly disclosed.
need to attach them now but the administrator
may call for any document or evidence to
Please provide details of any documents which support your
substantiate the claim at their discretion as may
claim eg. sales invoices, delivery notes etc. Please also provide
the chairman or convenor of any meeting).
copies of documentation where requested by the administrator.
6 If the amount in 4 above includes outstanding
Confirm the amount of any uncapitalised interest where this has
been included in Box 4 above.
uncapitalised interest, please state the amount.
7 Particulars of how and when the debt incurred.
(If you need more space, append a continuation
Please provide a brief summary of how the debt was incurred.
sheet to this form).
8 Particulars of any security held, the value of the
If you believe you have any security, enter your estimate of the value of the security
you hold i.e. mortgages or charged assets. Also confirm the date of the security.
security, and the date it was given.
9 Particulars of any reservation of title claimed in
If you believe there are retention of title rights in relation to this
claim, enter your estimate of the value of the goods covered by
respect of the goods supplied to which the claim
retention of title.
10 Signature of creditor or person authorised to act
You MUST sign the form and include your name in BLOCK
on his behalf.
IF you are completing the form as an individual, please state your relationship to
the insolvent entity (i.e. employee or customer). If you are completing the form on
Position with or relation to creditor
behalf of a company or limited partnership please state your role (e.g. Account
Manager, Finance Director or Partner).
Address of person signing (if different from 2
Only complete this section if your contact address in relation to
this matter is not the same as the address provided in Box 2.
Please date on completion.


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