Name and postal address of creditor in full:
Telephone No: [area code and number]
My reference is (if applicable):
*Any personal information collected is for the purpose of administering the liquidation in accordance with the Companies Act 1955.
The information will be used and retained by [name and address of agency collecting and holding information] and will be released to other parties only with your authorisation or in compliance with the Privacy Act 1993.
Under section 279(4) of the Companies Act 1955 the valuation and claim made by a secured creditor claiming as an unsecured creditor against a company in liquidation for the balance due must be in this prescribed form and must—
contain full particulars of the valuation and any claim; and
contain full particulars of the charge including the date on which it was given; and
identify any documents that substantiate the claim and charge.
You may have access to and request correction of any personal information.
|*Not applicable, if creditor is not an individual within the meaning of the Privacy Act 1993.|
Name of company in liquidation: [company name] (in liquidation)
I [name] [if claim is made on behalf of creditor, specify relationship to creditor and authority] claim that after valuing the security as at the date the company was put into liquidation the abovenamed creditor is an unsecured creditor of the company for the sum of: [amount in words and figures]
Full particulars of the valuation, claim, and charge are set out, and any supporting documents that substantiate the claim and the charge, are identified on the reverse of this form.
(The liquidator may require the production of a document under section 279(5) of the Companies Act 1955. You are not required to attach any supporting documents at this stage, but you may attach them now, if you think it would expedite the processing of the claim.)
It is an offence under section 279(11) of the Companies Act 1955 to—
make, or authorise the making of, a claim that is false or misleading in a material particular knowing it to be false or misleading; or
omit, or authorise the omission, from a claim of any matter knowing that the omission makes the claim false or misleading in a material particular.
Reserved for office use
Claim admitted for voting purposes: [signature] [date]
Claim rejected for voting purposes: [signature] [date]
Claim rejected for payment: [signature] [date]
Claim admitted for payment
Preferential claim for: $[amount]
Ordinary claim for: $[amount]
Note: If the decision to admit or reject a claim is amended, regulation 8 of the Companies Act 1955 Liquidation Regulations 1994 requires that it be recorded in writing.
Valuation of security
|Particulars of the charge|
Description and location of property subject to charge:
Date charge given (or date of acquisition of property subject to the charge):
If applicable, details of registration (including date):
|Particulars of the valuation|
Amount security valued at: $
Particulars of valuation:
|Identification of any documents that substantiate the claim and the charge|
(If not already supplied in either of above boxes)