IN THE (HIGH) COURT OF __________________

IN the matter of the Indian Companies Act, 1956

And

The matter of the liquidation of ________ Co. Ltd.

I, …………………………………………………………………… ,
Aged……………………………………………………………. years,
son of _________________________________ ,
resident of ____________________________ , do hereby on oath /on solemn affirmation state as
follows:

1. That the above-named company was on the ____________________ day of ________ , ______ , the date of the order for winding up the same, and still is justly and truly indebted to me in the sum of Rupees _________________________________________________ (Rs in words ) only on account of (describe briefly the nature of the debt).

2. That in proof of the aforesaid debt I attach hereto the documents marked …………………………………………………

3. That I have not, nor have any person or persons by my order or to my knowledge or belief for my use, received the aforesaid sum of Rupees __________________________ or any part thereof, or any security or satisfaction for the same or any part thereof except the sum or security (state the exact amount of security).

4. That this affidavit is true, that it conceals nothing and no part of it is false

AA

Signature

VERIFICATION

I, _____________________________the above named deponent do hereby verify on oath that the contents of the affidavit above are true to my personal knowledge and nothing material has been concealed or falsely stated. Verified at ______ this _____day of ______

DEPONENT