PROOF OF DEBT - GENERAL FORM

PETROPAVLOVSK PLC (in Administration)

Date of Administration: 18 July 2022		

	DETAILS OF CLAIM	
	
1.	Name of Creditor (if a company, its registered name)		
2.	Address of Creditor (i.e. principal place of business)	

3.	If the Creditor is a registered company:
•	For UK companies: its registered number 
•	For other companies: the country or territory in which it is incorporated and the number if any under which it is registered
•	The number, if any, under which it is registered as an overseas company under Part 34 of the Companies Act		
4.	Total amount of claim, including any Value Added Tax, as at the date of administration, less any payments made after this date in relation to the claim, any deduction under R14.20 of the Insolvency (England & Wales) Rules 2016 and any adjustment by way of set-off in accordance with R14.24 and R14.25	
£	
5.	If the total amount above includes outstanding uncapitalised interest, please state 	YES (£                   ) / NO	
6.	Particulars of how and when debt incurred	
	
7.	Particulars of any security held, the value of  the security, and the date it was given
		
8.	Details of any reservation of title in relation to goods to which the debt relates		
9.	Details of any document by reference to which the debt can be substantiated. [The administrator may call for any document or evidence to substantiate the claim at his discretion.]		
10.	Give details of whether the whole or any part of the debt falls within any (and if so which) of the categories of preferential debts under section 386 of, and schedule 6 to, the Insolvency Act 1986 	Category

Amount(s) claimed as preferential £	
11.	If you wish any dividend payment that may be made to be paid in to your bank account please provide BACS details. Please be aware that if you change accounts it will be your responsibility to provide new information	Account No.:

Account Name:

Sort code:	
	AUTHENTICATION	
	
Signature of Creditor or person authorised to act on his behalf	

Name in BLOCK LETTERS	
	
Date	
	
If signed by someone other than the Creditor, state your postal address and authority for signing on behalf of the Creditor		
Are you the sole member of the Creditor?	YES / NO