Creditor Particulars To be attached to the Claim Form

Creditor Particulars To be attached to the Claim Form NAME OF THE ESTATE: PERSONAL / COMPANY PARTICULARS Should any of the details below change, please notify us immediately. NAME (AND SURNAME): POSTAL ADDRESS: CONTACT DETAILS WORK: HOME: FAX: MOBILE: EMAIL: ALTERNATE CONTACT FULL NAME: RELTIONSHIP: CONTACT DETAILS: BANKING DETAILS The Master of the High Court has now authorized any dividend payments via EFT. Kindly provide us with your banking details for use if dividends are ultimately payable. In the event of you not so doing, dividends will be issued by cheque and forwarded to your postal address via surface mail. BANK: NAME OF ACCOUNT: TYPE OF ACCOUNT: BRANCH: BRANCH CODE: ACCOUNT NUMBER:

RTC/CS CLAIM NO. AFFIDAVIT for the proof of any claim other than a claim on Promissory Note or other Bill of Exchange. (Section) 44(4)). BEËDIGDE VERKLARING tot bewys van n ander eis as n eis op grond van n Promesse of ander Wissel. (Artikel 44(4)). (1) IN THE INSOLVENT ESTATE OF. IN DIE INSOLVENTE BOEDEL VAN (hereinafter referred to as the said Insolvent) (2) NAME IN FULL OF CREDITOR. NAAM VOLUIT VAN SKULDIESER (hereinafter referred to as the said Creditor) (hierin voortaan na verwys as genoemde Skuldeiser) (3) ADDRESS IN FULL VOLLEDIGE ADRES TOTAL AMOUNT OF CLAIM R (4) P.O. BOX NO./POSBUS NR.. (5) TOTALE BEDRAG VAN EIS (6) I, do hereby make oath and say: EK, verklaar hiermee onder eed en sê: (7) That I am of (2).. Dat ek die is van (hereinafter referred to as the said Creditor) (hierin voortaan na verwys as genoemde Skuldeiser) That I have personal knowledge of the facts hereinafter stated. Dat ek persoonlik kennis dra van die feite herein uiteengesit. (1) That. Dat (hereinafter referred to as the said Insolvent) whose estate has been sequestrated was at the date of sequestration and still in indebted to the said Creditor in the sum of van wie die boedel gesekwestreer is, op die dag van sekwestrasie en nou nog, verskuldig is aan die genoemde Skuldeiser is die som van (8) (words) (woorde) (9) for vir That the said debt arose in the manner and at the time set forth in the account hereunto annexed. Dat genoemde skuld ontstaan het op die wyse en op die datum soos op hierby aangehegte rekening uiteengesit. That no other person besides the said Insolvent is liable (otherwise than as surety) for the said debt or any part thereof. Dat geen ander persoon buiten die genoemde Insolvent vir die genoemde skuld of enige deel daarvan aanspreeklik is nie (behalwe as borg). That the said Creditor has not, nor has any other person, to my knowledge on the said Creditor s behalf received any security for Dat nog die genoemde Skuldeiser, nog volgens my wete, enige ander persoon namens die genoemde Skuldeiser enige sekuriteite the said debt or any part thereof save and except vir die genoemde skuld of enige deel daarvan ontvang het nie, buiten en behalwe (10).. which security I value at welke sekuriteit ek warder teen R.. That this claim was not acquired by cession after the institution of the proceedings by which the Estate was sequestrated. Dat die eis nie verkry is deur sessie na die instelling van die proses vir the sekwestrasie van die boedel nie. (11) Signature of Declarant.. Handtekening van Deklarant I certify that this Affidavit was Signed and Sworn to before me on the day of.. 20 Ek sertifiseer dat hierdie Beëdigde Verklaring Geteken en Beëdig is voor my of die dag van at by the deponent who has acknowledged that he knows and understands the contents of this Affidavit. te deur die deponent wie verklaar het dat hy vertroud is met the inhoud van hierdie Beëdigde Verklaring. NO REVENUE STAMPS REQUIRED GEEN INKOMSTE SEEK BE- NODIG NIE COMMISSIONER OF OATHS FULL NAME. ADDRESS

AFFIDAVIT FOR THE PROOF OF CLAIM ON A PROMISSORY NOTE OR OTHER BILL OF EXCHANGE. (Section 44 (4)) BEËDIGDE VERKLARING VIR DIE BEWYS VAN N EIS GEBASEER OP N PROMESSE OF ANDER WISSEL. (Artikel 44 (4)) CLAIM NO.: (1) In the Insolvent Estate of.. (hereinafter referred to as the said Insolvent) In die Insolvente Boedel van (2) Name in Full of Creditor (hereinafter referred to as the said Creditor) Naam Voluit van Skuldeiser (hierin voortaan na verwys as genoemde Skuldeiser) (3) Address in Full (4) P.O. Box No.. Volledige Adres Posbus Nr. (5) Total Amount of Claim R.. Totale Bedrag van Eis (6) I,.. do hereby make oath and say: Ek, verklaar hiermee onder eed en sê: (7) That I am (2) of.. (hereinafter referred to as the said Creditor) Dat ek die is van (hierin voortaan na verwys as genoemde Skuldeiser) That I have personal knowledge of the facts hereinafter stated. Dat ek persoonlik kennis dra van die feite hierin uiteengesit. (1) That.(hereinafter referred to as the said Insolvent) Dat whose estate has been sequestrated, was at the date of sequestration and still is justly and truly indebted to the said Creditor in the sum of (words) (8) van wie die boedel gesekwestreer is, op die dag van sekwestrasie en nou nog, regverdiglik en wettiglik verskuldig is aan genoemde Skuldeiser, in die som van (woorde) by virtue of the following Promissory Notes or other Bill of Exchange. Kragtens die volgende Promesse of ander Wissel. Date of Note or Bill Datum van Promesse of Bewys Name of drawer or Maker Naam van Ondertekenaar of Trekker Name of Acceptor Naam van Akseptant Name of person to whom payable Naam van persoon aan wie betaalbaar Date when payable Datum waarop betaalbaar Name of Endorser Naam van Endossant Amount Bedrag That the said debt arose in the manner and at the time set forth in the account hereto annexed. Dat genoemde skuld ontstaan het op die wyse en op die datum soos op die hierby aangehegte rekening uiteengesit. (10) That the said Creditor has not, nor has any other person to my knowledge on the said Creditor s behalf, received any security for the said debt or any part thereof, save and except Dat nog die genoemde Skuldeiser, nog volgens my wete, enige ander persoon namens die genoemde Skuldeiser enige sekuriteit vir die genoemde skuld of enige deel daarvan ontvang het nie, buiten en behalwe which security I value at R welke sekuriteit ek warder teen That besides the said Insolvent, one mentioned above is liable to the said Creditor as.. of the said Note/Bill as aforesaid. Dat buiten die genoemde Insolvent, een soos bovermeld, aanspreeklik is aan genoemde skuldeiser as van die genoemde Promesse/Bewys soos voornoem. That the said Note/Bill is in all respect genuine and valid. Dat die genoemde Promesse/Bewys is in all aspekte eg en geldig is. That the claim was not acquired by cession after the institution of the proceedings by which the Estate was sequestrated. Dat die eis nie verkry was nie deur sessie na die instelling van die aksie waardeur die boedel gesekwestreer is. (11) Signature of Declarant. Handtekening van Deklarant NO REVENUE STAMPS REQUIRED GEEN INKOMSTE SEELS BENODIG NIE I certify that this Affidavit was Signed and Sworn to before me on the. day of 20. Ek sertifiseer dat hierdie Beëdigde Verklaring Geteken en Beëdig is voor my of die dag van 20. by the Deponent who has acknowledged that he knows and understands the contents of this Affidavit. deur die Deponent wie verklaar het dat hy vertroud is met die inhoud van hierdie Beëdigde Verklaring. COMMISSIONER OF OATHS. FULL NAME.... ADDRESS...

STATEMENT OF ACCOUNT (IN TERMS OF SECTION 44(6) OF THE INSOLVENCY ACT, AS AMENDED) IN THE CASE OF CLAIM BEING IN RESPECT OF GOODS SOLD AND DELIVERED ON AN OPEN ACCOUNT, THIS STATEMENT SHOULD BE COMPLETED IN EVERY RESPECT AND ATTACHED TO YOUR CLAIM DOCUMENT NAME OF ESTATE NAAM VAN BOEDEL NAME OF CREDITOR NAAM VAN SKULDIESER.. BRIEF DESCRIPTION OF GOODS KORT BESKRYWING VAN DOEDERE DETAILS OF SALES BESONDERHEDE VAN VERKOPE DATE DATUM INVOICE No. FAKTUUR Nr. AMOUNT BEDRAG MONTHLY TOTALS (Not Progressive MAANDELIKSE TOTALE (Nie Toenemend) TOTAL DEBITS A TOTALE DEBIETE A DETAILS OF PAYMENTS RECEIVED AND CREDITS ALLOWED BESONDERHEDE VAN BETALINGS ONTVANT EN KREDIETE TOEGESTAAN DATE DATUM PAYMENT OR CREDIT BETALING OF KREDIET AMOUNT BEDRAG MONTHLY TOTALS (Not Progressive) MAANDELIKSE TOTALE (Nie Toenemend) TOTAL CREDITS B TOTALE KREDIETE B AMOUNT OF CLAIMS AS PER AFFIDAVIT i.e. A less B BEDRAG VAN EIS SOON VERKLARING d.w.s. A min B NOTE: L.W. 1. A and B must reflect full period of trading for a period of 12 months before date of liquidation/sequestration/judicial management, whichever is the lesser. 2. If no payments were received, or credits given, state NIL under B. 3. A brief description of the goods sold must be given i.e. Clothing, Groceries etc. 1. A en B moet die volle handelstydperk aandui, of n tydperk van 12 maande voor likwidasie/sekwestrasie/geregtelike bestuur, wat ook al die kortste is. 2. Indien geen betalings ontvang of krediete toegestaan is nie, toon NUL onder B. 3. n Kort beskrywing van die goedere verkoop moet gegee word, d.w.s. Klerasie, Kruidenniersware ens.

POWER OF ATTORNEY TO PROVE CLAIMS ETC. PROKURASIE VIE DIE BEWYS VAN EISE ENS. I, the undersigned, Ek, die ondergetekende in my capacity as.. in my hoedanigheid as of.. van (hereinafter referred to as the said Creditor) do hereby nominate, constitute and appoint.. (hierna verwys as die genoemde Skuldeiser) benoem, konstitueer en stel hierby aan and / or en / of with power of substitution to the said Creditor s lawful Attorney and Agent in the said Creditor s name, place and stead, to attend en met Mag van Substitusie om die genoemde Skuldeiser se wettige Prokureur en Agent to wees, en in die genoemde all meetings of Creditors in the matter of Skuldeiser se naam en namens die genoemde Skuldeiser alle vergaderings van Skuldeisers by te woon, in die saak van.. on the said Creditor s behalf to prove the said Creditor s claim and to exercise on the said Creditor s behalf all voting and other en namens die genoemde Skuldeiser, die genoemde Skuldeiser se eis to bewys, en om namens die genoemde Skuldeiser te powers in respect of such claim particularly in respect of the appointment of a Trustee/Liquidator/Judicial Manager and/or stem en om alle magte uit te oefen ten opsigte van sodanige eis met betrekking tot die aanstelling van n Kurator/Likwidateur/ any offer of Composition and/or submission to arbitration of any dispute and/or the Composition or admission of any claim Geregtelike Bestuurder en/of enige aanbod van Komposisie en/of voorlegging tot arbitrasie van enige dispuut en/of die against the Estate/Company and to give the Trustee/s/Liquidator/s/Judicial Manager/s directions as to the administration of the Komposisie of toelating van enige eis teen die Boedel/Maatskappy en om aan die Kurator/e/Likwidateur/s/Geregtelike Estate/Company and generally to act on the said Creditor s behalf at all meetings of the Estate/Company in all matters and Bestuurder/s aanduidings to gee, in verband met die administrasie van die Boedel/Maatskappy en om in die algemeen op te things in which the said Creditor s interests are concerned, hereby promising to ratify and confirm whatsoever the said Agent tree namens die genoemde Skuldeiser op alle vergaderings van die Boedel/Maatskappy in alle sake waarin die genoemde may do or perform by virtue of these presents. Skuldeiser belange het, en belowe hiermee om goed to keur en to bekragtig wat ook al die genoemde Agent mag doen of te weeg bring uit krag hiervan. DATED AT. this.. day of.. 20.. GEDATEER TE hierdie dag van 20.. AS WITNESSES: AS GETUIES: 1... SIGNATURE/HANDTEKENING 2...

(PTY) LIMITED/CC* (EDMS) BEPERK/BK* CERTIFIED EXTRACT FROM THE MINUTES OF A MEETING OF DIRECTORS/MEMBERS * OF THE ABOVEMENTIONED GESERTIFISEERDE UITTREKSEL VAN DIE NOTULE VAN n VERGADERING VAN DIE DIREKTEUR/LEDE * VAN COMPANY/CLOSE CORPORATION * HELD AT BOVERMELDE MAATSKAPPY/BESOLTE KORPORASIE * GEHOU TE ON THE DAY OF 20 OP DIE DAG VAN 20 IT WAS RESOLVED: DIT WAS BESLUIT: That Mr. Dat Mnr. a Director/Member/Secretary/Accountant/Official* n Direkteur/Lid/Sekretaris/Rekenmeester/Amptenaar* of the Company/Close Corporation*, be and is hereby authorized and empowered to nominate a provisional Trustee/Liquidator on van die Maatskappy/Beslote Korporasie*, hiermee gemagtig word om n voorlopige Kurator/Likwidateur namens die Maatskappy/Beslote behalf of the Company/Close Corporation* and to sign all the necessary documents to enable the Company/Close Corporation* to prove Korporasie* to nomineer en om alle nodige dokumente to onderteken om die Maatskappy/Beslote Korporasie* in staat te stel om hulle Its claim against Eis to bewys teen to attend meetings of creditors of the said Estate/Company/Close Corporation*, and to speak and vote on behalf of the Company/Close en om alle vergaderings van Skuldeisers van die genoemde Boedel/Maatskappy/Beslote Korporasie* by te woon en to stem namens die Corporation* with power, in his discretion to substitute and appoint any other person or persons to attend such meetings on the Maatskappy/Beslote Korporasie* volgens sy diskressie, met die mag van substitusie, en om enige persoon of persone to benoem om Company s/close Corporation* behalf and to vote thereat. Sodanige vergaderings namens die Maatskappy/Beslote Korporasie* by te woon en daar te stem. CERTIFIED A TRUE COPY GESERTIFISEER n WARE AFSKRIF NOTE: DELETE WHICH EVER IS NOT APPLICALBE* LET WEL: KRAP DIE WAT NIE TOEPAS NIE* AUTHORISED OFFICIAL GEMAGTIGDE AMPTENAAR