Insolvency Act, 1936 (Act No. 24 of 1936)SchedulesFirst Schedule : FormsForm 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 |
Date |
Name of endorser |
Amount |
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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. |