Xanthea Pty Ltd

INFORMAL PROOF OF DEBT OR CLAIM
Bankrupt Estate of John Charles Jury SA 667 of 2019/2
To the Official Trustee of John Charles JURY SA 667 of 2019/2 (the “Bankrupt”)

1. This is to state that the Bankrupt was on 23 August 2019, and still is, justly and truly indebted to:
Full name, ABN & address of creditor &, if applicable, the creditor's partners. (If prepared by an employee or agent of the creditor, also insert a description of the occupation of the creditor)
Full Name:*
ABN:
Address:*

Street Address

Street Address Line 2

CityState

Post Code
for
dollars and cents
2. To my knowledge or belief the creditor has not, nor has any person by the creditor's order, had or received any satisfaction or security for the sum or any part of it, except for the following:
(insert particulars of all securities held. If the securities are on the property of the company, assess the value of those securities. If any bills or other negotiable securities are held, show them in a schedule in the following form).
Signed by (select option)*

I am the creditor personallyI am employed by the creditor and authorised in writing by the creditor to make this statement. I know that the debt was incurred for the consideration stated and that the debt, to the best of my knowledge and belief, remains unpaid and unsatisfied.I am the creditor's agent authorised in writing to make this statement in writing. I know the debt was incurred for the consideration stated and that the debt, to the best of my knowledge and belief, remains unpaid and unsatisfied.
Signature*

Clear
Date

MonthDayYear
Date
Name*

First NameLast Name
Position*
Address

Street Address

Street Address Line 2

CityState

Post Code
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Bankrupt Estate of John Charles Jury SA 667 of 2019/2

RECEIVE INFORMATION ELECTRONICALLY