Insolvency Act, 1936 (Act No. 24 of 1936) > Schedules > First Schedule : Forms > Form C : Affidavit for proof of any claim

FORM C

AFFIDAVIT FOR THE PROOF OF ANY CLAIM OTHER THAN A CLAIM BASED ON A PROMISSORY NOTE OR OTHER BILL OF EXCHANGE (SECTION 44(4)).

In the Insolvent Estate of __________________________________________

Name in full of creditor __________________________________________

Address in full _________________________________________

Total amount of claim _________________________ £ _______________

I, __________________________________________________declare under oath/

Solemnly and sincerely declare *

1)	That ___________________________ , whose estate has been sequestrated, was at the date of sequestration, and still is, indebted to ___________________________________________ in the sum of ______________________________________________________________

for ______________________________________________________________

2)	That the said debt arose in the manner and at the time set forth in the account hereunto annexed.

3)	That no other person besides the said_______________________________

is liable (otherwise than as surety) for the said debt or any part thereof.

That I have/ the said _____________________________________ has * not, nor has any other person, to my knowledge on my/his * behalf received any security for the said debt or any part thereof, save and except † ______________________________________________________________

______________________________________________________________

Signature of declarant ___________________________

Sworn / Solemnly declared * before me on the _____day of __________________

at_______________________.

_____________________________________________

Commissioner of Oaths.

*	Strike out inappropriate words according to the facts of the case.

†	Here insert nature, particulars and value of mortgage, pledge or other security.