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IN THE MATTER OF: (Insolvent or CC or Company)

Crocker Property (Pty) Ltd t/a Vista Homes

(under Business Rescue) hereinafter referred to as "the debtor"

Name of Creditor: / Amount of Claim:
Postal Address: / Account No/Ref:
Telephone Number : / Bank Account Details:
E-mail address :

I, the undersigned, ______

*do hereby make Oath and say that : I do solemnly and sincerely declare that : *

I. + I depose to this affidavit *in my capacity as of the creditor (duly authorised by power of attorney, a copy of which is annexed hereto marked "A")/ being fully cognizant of the claim in that I have full knowledge of the facts set out hereinafter from the books and records pertaining to the claim under my control*.

II. The debtor *whose estate has been placed under Business Rescue*, was at the date of Business Rescue still is indebted to the creditor in the sum of (amount in words):-

______

Arising from :

______

IIII. The said debt arose in the manner and at the time set forth in the account hereunto annexed, marked "B".

IV. No person besides the debtor is liable (other than as surety) for the said debt or any part thereof.

V. That the creditor has not, nor has any other person to my knowledge on *my/its behalf received any security for the said debt or any part thereof, save and except :

*a) Type of Security ______b) Amount of such security ______

c) when such security was issued d) by whom such security was issued ______

e) on the terms and conditions which appear from a true copy of such security, annexed hereto marked "C"*.

VI. I value the said security at the sum of R ______

We do/do not* rely for the satisfaction of our claim solely on the proceeds of the realisation thereof.

Signature of *deponent / declarant*
______
*(NOTE : NB DEPONENT TO SIGN BEFORE COMMISSIONER)

The Deponent acknowledges that he/she knows and understands the contents of this Affidavit which was signed and sworn to before me at ______on the______day of______the regulations contained in Government Notice R1258 of the 21 July 1972 (as amended), having been complied with.

COMMISSIONER OF OATHS

FULL NAMES

ADDRESS

CAPACITY

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ANNEXURE B

STATEMENT OF ACCOUNT

In the case of the claim being in respect of goods sold and delivered on an open account, this statement must be completed in every respect and attached to your claim documents. This statement complies with the amendments of the Insolvency Act.

NAME AND ADDRESS OF CREDITOR:

NAME OF COMPANY : Crocker Property (Pty) Ltd t/a Vista Homes

BRIEF DESCRIPTION OF GOODS SUPPLIED :

"A" Monthly totals of goods supplied for 12 (twelve) months prior to liquidation / sequestration / judicial management / "B" - Total monthly payments received 12 (twelve) months prior to liquidation / sequestration / judicial management
Month before Liq/Seq / Month & Year / TOTAL / Repayments Received / Month & Year / TOTAL
13th Month / Balance if any
20 / R
12th Month / 20 / R / 12th Month / 20 / R
11th Month / 20 / R / 11th Month / 20 / R
10th Month / 20 / R / 10th Month / 20 / R
9th Month / 20 / R / 9th Month / 20 / R
8th Month / 20 / R / 8th Month / 20 / R
7th Month / 20 / R / 7th Month / 20 / R
6th Month / 20 / R / 6th Month / 20 / R
5th Month / 20 / R / 5th Month / 20 / R
4th Month / 20 / R / 4th Month / 20 / R
3rd Month / 20 / R / 3rd Month / 20 / R
2nd Month / 20 / R / 2nd Month / 20 / R
Exact date in Liq/Seq month / 20 / R / Exact date in Liq/Seq Month / 20 / R
TOTAL "A" / R / TOTAL "B" / R

AMOUNT OF CLAIM - TOTAL "A" MINUS "B" EQUALS

R ______

NOTES

1) A brief description of goods sold must be given: ie groceries, hardware, confectionery, clothing etc.

2) "A" and "B" must reflect full period of trading or for a period of twelve months before date of sequestration / liquidation / judicial management.

3) If no payments were received or credits given, state "NIL" under "B"


RESOLUTION

EXTRACT OF THE MINUTES OF A BOARD MEETING OF

NAME OF CREDITOR : ______

HELD AT : ______DATE : ______

RESOLVED :

In the matter of Crocker Property (Pty) Ltd t/a Vista Homes

Name of Deponent ______

be authorised to sign all documents on behalf of the company, to prove claims on behalf of

the company and to sign Powers of Attorney in favour of ______

with power of substitution to act on behalf of the company at any meeting of the creditors

convened in terms of the Companies Act.

SIGNED: ______

NAME: ______

CAPACITY: ______