Cap. 6:07 No. 7/2018 INSOLVENCY *Sworn to/ solemnly declared before me on: .. ....... (date) at .. ............... (place) Commissioner of oaths Full name Business address Designation and area or office FORM C (section 66(6)) AFFIDAVIT FOR THE PROOF OF A CLAIM BASED ON A PROMISSORY NOTE OR OTHER BILL OF EXCHANGE Strike out inapplicable words where* occurs. In the in sol vent 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: ............. . ..... declare *under oath/solemnly as follows I, .... ··················· ( l) *I am the creditor/I 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 \vas obtained by cession on.. ............. (date). The debtor was on the date of liquidation and still is indebted to me by \irtue of the following *promissory note/bill of exchange: (4) Date of note or bill I Name of maker or drawer Name of acceptor Name of person to whom payable I ' Date when payable Name of endorser Amount I I I (5) The nature of the claim (for instance money advanced, goods delivered, and 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 \\ere made a statement shall be submitted \Vith a brief description of all debits and credits mer the period of twelve months immediately preceding the date of liquidation.) 329