No. 7/2018 INSOLVENCY Cap.6:07 FORM B (Section 66(6)) AFFIDAVIT FOR PROOF OF ANY CLAIM OTHER THAN A CLAIM BASED ON A PROMISSORY NOTE OR OTHER BILL OF EXCHANGE Strike out inapplicable words where* occurs. In the insolvent estate of: .......................................................................................................................... . Date of liquidation: ....................................................................................................................................... . Name of creditor: ........................................................................................................................................... . Address of creditor: ....................................................................................................................................... . E-mail address of creditor: ........................................................................................................................ . Fax number of creditor: ............................................................................................................................... . Amount of claim at date of liquidation: .............................................................................................. . I, ......................................................................................... declare *under oath/solemnly as follows ( 1) *I am the creditor/! am the ....................................... (capacity) of the creditor and have authority to make this declaration and submit the claim for proof as appears from the attached documentation. (2) *I have personal knowledge of the nature and particulars of the claim/1 have satisfied myself as to the nature and particulars of the claim. (3) *The claim was not obtained by cession after the commencement of liquidation proceedings/The claim was obtained by cession on ....................... (date). (4) The nature of the claim (for instance money advanced, goods delivered, salary due) is .......................................................................................................... as appears from the attached documentation or declaration. (In respect of debts which accrued over a period or in respect of which payments were made a statement shall be submitted with a brief description of all debits and credits over the period of twelve months immediately preceding the date of liquidation.) (5) (6) The debt arose on or since ........................ (date). The debt was due to me on the date of liquidation/The debt or part thereof became due to me or will become due to me after liquidation as set out on the attached statement. *I hold no security in respect of the debt/The particulars of security held by me for payment of the debt and the value placed be me on the security (if a value is placed on the security) are as follows: *I do not rely on my security for the payment of my claim .II rely solely on my security for the payment of my claim. (7) *To the best of my knowledge no one except the insolvent estate is liable for the debt or a part thereof/The particulars of others who are to my knowledge liable for the debt and the security held in respect thereof are as follows ............................ . *(8) I authorise the liquidator to have any dividend due to me transferred electronically to my banking account (supply name of account, branch number and account number ..................................................................................................................................................... . Signature of declarant 328