Company name




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A.C.N. ________________

Sub-regulation 5.6.49(2)


FORM 535


Corporations Act 2001
FORMAL PROOF OF DEBT OR CLAIM (GENERAL FORM)
To the *administrators/liquidators of

(*strike whichever inapplicable)


COMPANY NAME

(ADMINISTRATION TYPE eg. IN LIQUIDATION etc)

1. This is to state that the company was on / / and still is, justly and truly


indebted to (1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


(If you are a business creditor, failure to quote your A.B.N.

may result in withholding of tax of 48.5% from any dividend by the administrator)

A.B.N. . . . . . . . . . . . . . . . . . . . . . . . .

for . . . . . . . . . . . . . . . . . . . . . . . . . . dollars and . . . . . . . . . . . . . . . . . . cents.

Particulars of the debt are:



Date

(2) Consideration

Amount

$ c


















2. To my knowledge or belief the creditor has not, nor has any person by the creditor's order, had or received any satisfaction or security for the sum or any part of it except for the following: (insert particulars of all securities held. If the securities are on the property of the company, assess the value of those securities. If any bills or other negotiable securities are held, show them in a schedule in the following form).




Date

Drawer

Acceptor

Amount

$ c

Due Date






























*3.(3) I am employed by the creditor and authorised in writing by the creditor to make this statement. I know that the debt was incurred for the consideration stated and that the debt, to the best of my knowledge and belief, remains unpaid and unsatisfied.


*3.(3) I am the creditor's agent authorised in writing to make this statement in writing. I know that the debt was incurred for the consideration stated and that the debt, to the best of my knowledge and belief, remains unpaid and unsatisfied.

Dated:
Signature:


Occupation:
Address:

NOTES
(1) Insert full name and address of the creditor and, if applicable, the creditor's partners. If prepared by an employee or agent of the creditor, also insert a description of the occupation of the creditor.
(2) Under "Consideration" state how the debt arose, for example "goods sold and delivered to the company between the dates of................................", "moneys advanced in respect of the Bill of Exchange".
(3) If proof is made by creditor personally, strike out the 2 paragraphs numbered 3.


FOR OFFICE USE ONLY

Date Rec'd :




Proof No. :




Creditor Code :




ROA Amount :




Lodged :




Entered :




Admit :




Reject :




Heldover :




Withdrawn :




Authority :




Entered :





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