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Insolvency Act, 1936 (Act No. 24 of 1936)

Schedules

First Schedule : Forms

Form D : Affidavit for the proof of a claim based on a Promissory Note or other Bill of Exchange (Section 44(4))

 

FORM D

 

AFFIDAVIT FOR THE PROOF OF 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 on the date of sequestration, and still is, indebted to _______________ in the sum of _____________, by virtue of the following promissory note / bill of exchange *

 

 

Date of note or bill

Name of maker or drawer

Name of acceptor

Name of person
to whom payable

Date
when payable

Name of endorser

Amount

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

3) 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

† ______________________________________________________________

 

 

4) That besides the said _______________________________one _________________________ mentioned above, is liable to me / the said _________________________*  of the said note / bill *as aforesaid.

 

5) That the said note /bill * is in all respects genuine and valid.

 

 

 

 

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.

 

 


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