Principle Liquidation

Creditors Claim form (Proof of debt)

For use in Liquidations and Insolvency matters pursuant to section 304(1) of the Companies Act 1993

1. Debtor Details

Name of Insolvent Company:

Company Number:

2. Creditor Details

Name of Creditor:

Name of contact person if applicant creditor is an organisation:

Postal Address:

GST Number:

Phone Number (Daytime):

Email Address:

State that as at the date of the Liquidation that the debtor above was indebted to the above named creditor for the sum of

Sum in Words:

Total GST included in your claim:

Security is held for the payment of the whole of part of the above amount

Yes

Name of Security:

Property Secured:

Estimated value of property secured:

Date Guarantee Given:

Please provide a reference number (For example, account number) that we can quote when communicating with you about this claim:

Please provide your bank account details for any dividend payment:

Account Name:

Account Number:

Bank

Branch

Account

Suffix

3. Debt Details

Details of debt

Details of Items Supplied	Date of Supply	Amount $	Upload File	Action
			Please attach evidence of the basis for this claim i.e. Invoices

Date Uploaded	Document Name	Remove

Details of Interest

		Amount $	File Upload	Action
Does your claim include interest?	Yes No		Please attach evidence of the basis for this claim i.e. Contract allowing interest charges

Date Uploaded	Document Name	Remove

Important information

*Any personal information collected is for the purposes of administering the Bankruptcy or Company in Liquidation. The information will be used and retained by Principle Insolvency Limited and will be released to other parties only with your authorisation or in compliance with the Privacy Act 1993, the Insolvency Act 2006 and the Companies Act 1993 or any corresponding Regulations. You may have access to and request correction of any personal information. You are obliged to provide this information. (*Not applicable if the creditor is not an individual within the meaning of the Privacy Act 1993).

I declare that the information given in this Claim Form is true and correct and by signing this form I confirm that I am not committing an offence as outlined

Date:

Time:

IP Address:

Location:

Creditors Claim form (Proof of debt)

1. Debtor Details

2. Creditor Details

3. Debt Details

Important information

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