Unsecured Creditor'S Claim Proof Of Debt

UNSECURED CREDITOR’S CLAIM

Proof of Debt

0800 CLOSED (256733)

·

·

F. 0800 FAX WSI (329974)

E. enquiries@waterstone.co.nz P.O. Box 352, Shortland Street, Auckland

For use in Voluntary Administrations and Liquidations under the Companies Act 1993 and in Receiverships under the Receiverships Act 1993.

NAME OF DEBTOR

Liquidation

Voluntary Administration

Receivership

(In case of a partnership, insert full names of all partners)

NAME OF CREDITOR

POSTAL ADDRESS

GST NUMBER

(

)

(

)

PHONE

FAX

EMAIL **

I do not want email communication

** this will be used as your address for correspondence unless you tick this box.

I

[if claim is made on behalf of creditor, specify relationship to creditor and authority] claim that the company was at the date it was put into liquidation/receivership/voluntary adminis-

$

tration indebted to the above-named creditor for the sum of:

(amount in figures)

(amount in words)

$

Total GST included in your claim (if applicable):

OR

I hold no security for the amount claimed

I am surrendering my security and I am claiming as an unsecured creditor

If you wish to receive any dividend payments by electronic transfer please provide the following information:

ACCOUNT NAME

/

/

/

ACCOUNT NUMBER

Bank

Branch

Account number

Suffix

PARTICULARS OF CLAIM

(Please attach supporting evidence)

Full particulars of the claim are set out, and any supporting documents that substantiate the claim are identified below. (The liquidator may require the production of a document under section 304(1)(b) of the

Companies Act 1993. You are not required to attach any supporting documents at this stage, but you may attach them now, if you think it would expedite the processing of the claim.)

Date of Supply

Description of Goods or Services Supplied

Amount $

$

$

$

$

$

$

Does your claim include interest?

Yes

No

Amount:

Please attach evidence for the basis of this.

WARNING: It is an offence under section 304(6) of the Companies Act 1993 to make, or authorise the making of, a claim that is false or misleading in a material particular knowing

it to be false or misleading; or omit, or authorise the omission, from a claim of any matter knowing that the omission makes the claim false or misleading in a material particular.

*Any personal information collected is for the purpose of administering the liquidation in accordance with the Companies Act 1993. The information will be used and retained by Waterstone Insolvency Limited

and will be released to other parties only with your authorisation or in compliance with the Privacy Act 1993. Under section 304(1) of the Companies Act 1993 any claim by an unsecured creditor against a

company in liquidation must be made in this prescribed form and must— (a)contain full particulars of the claim; and (b)identify any documents that evidence or substantiate the claim. You may have access to

and request correction of any personal information.*Not applicable, if creditor is not an individual within the meaning of the Privacy Act 1993.

SIGNED:

DATE:

RESERVED FOR OFFICE USE

CLAIM ADMITTED FOR PAYMENT

Preferential claim for:

$ ____________________________________

RECEIVED

Ordinary claim for:

$ ____________________________________

SIGN AND DATE (Liquidator)

Deferred claim for:

$ ____________________________________

Claim admitted for voting purposes: ______________________________________

SIGNED (Liquidator):

Claim rejected for voting purposes: ______________________________________

DATE:

Claim rejected for payment:

______________________________________

Note: If the decision to admit or reject a claim is amended, regulation 8 of the Companies Act 1993

Liquidation Regulations 1994 requires that it be recorded in writing.