I, ....... of ....... make oath and say as follows:—

1. The above-written [or within-written] document is a true copy of the deed of assignment of property [or as the case may be], and of every schedule or inventory thereto annexed or therein referred to, and of every attestation of the execution thereof.

2. [Where the deed is executed by the debtor] The deed was executed on the ....... day of 19 , by the debtor, at ....... of the clock in the ....... noon. I was present when the debtor executed the said deed. and saw him execute the same.

3. [Where the deed is executed by a creditor:] The deed was executed by ....... the first [or only] creditor who executed the deed and who resides at ....... , and is ....... , on the ....... day of ....... at ....... of the clock in the ....... noon. I was present when the said ....... executed the said deed, and saw him execute the same.

4. The debtor, ....... , resides at ....... and is

5. The place [or places] where business of the said debtor is carried on is [or are] as follows:—

....... Sworn, &c.

make oath and say as follows—

1. On the ....... day of ....... , I executed a deed of assignment of property [or as the case may be

2. The total estimated amount of my property included under the deed is £ ....... and the net amount of my property included under the deed, after deducting £ ....... , being the value* of securities held by creditors and required to cover debts due to them, is £ .

3. The total estimated amount of my liabilities included under the deed is £ ....... , and the net amount of my liabilities included under the deed, after deducting £ ....... , being the amount† covered by securities held by creditors is £ .

4. [If composition payable:] The total amount of the composition payable thereunder is:

5. The names and addresses of my creditors and the amounts due to or claimed by each of them are as follows:

Sworn, &c.

*The estimated surplus (if any) from securities held by creditors should not be deducted from the gross amount of property.

†This amount should correspond with the amount of securities deducted above. No deduction should be made in respect of the unsecured balances of partially secured debts.

No.

Name address and description of debtor

Place(s) where business is carried on

Title of firms under which debtor carries on business

Name and address of trustee (if any)

Nature and effect of deed and amount of composition in the £

Amount of property as estimated by debtor

Amount of liabilities as estimated by debtor

Date of deed

Date of registration

Gross amount of property

Value of securities given (excluding any estimated surplus)

Net value of property

Gross amount of liabilities

Amount of debts covered by securities

Net amount of liabilities

...

...

...

...

...

...

...

£

£

£

£

£

....... I, ....... of

make oath and say as follows:—

1. The place [or places] where my business is carried is [or are]

2. The title [or titles] of the firm [or firms] under which I carry on business on is [or are]

3. The total estimated amount of my property is £ ....... and the net amount of my property, after deducting £ ....... being the value of securities held by creditors and required to cover debts due to them, is £

4. The total estimated amount of my liabilities is £ ....... and the net amount of my liabilities, after deducting £ being the amount covered by securities held by creditors, is £

5. The names and addresses of my creditors and the amounts due to or claimed by them are as follows:—

Sworn, &c.