/ CLAIM FORM
(See instructions on the backside) / FOR ADMINISTRATION ONLY
Secured :
Unsecured :
Original : / Amended:
Received on: / Initials

IN THE MATTER OF THE LIQUIDATION OF:

9342-8530 Québec Inc. (formerly DiagnoCure Inc.), from the city of Quebec, Province of Quebec (referred to in this form as “the company”)

and the claim of (referred to in this form as “the creditor”)

All notices or correspondence regarding this claim to be forwarded to the creditor at the following address:

Telephone: Fax:

I, residing in the city/town of

(name of person signing claim)(city, town, etc.)

in the Province of

If you represent the Creditor, state what position or title. / I am the Creditor OR
I am ______of the Creditor.
I have knowledge of all the circumstances connected with the claim referred below.
The attached statement of account or affidavit must specify the vouchers or other evidence in support of the claim. / 3.The debtor was, at the date of the commencement of the liquidation, namely June 6, 2016, and still is, indebted to the creditor in the sum of $ , as specified in the statement of account (or affidavit) attached hereto and marked Schedule “A”, after deducting any counterclaims to which the debtor is entitled.
Write in the amount of the unsecured claim against the Company. / UNSECURED CLAIM IN THE AMOUNT OF: $.
In respect of this debt, The Creditor does not hold any assets of the Debtor as security;
Write in the amount of the secured claim against the Company. / SECURED CLAIM IN THE AMOUNT OF: $.
In respect of this debt, the creditor holds assets of the Debtor valued at
$ as security, particulars of which are provided hereafter.
Write in the amount of the claim against administrators of the Company. / CLAIM TO THE AMOUNT OF: $______against ______.
DATED AT ______, this ______day of ______2015.
______/ ______
(Signature of Witness) / Signature of Creditor (or representant of the Creditor)
(Please print name) / (Please print name)

Instructions for completing your Claim form

The duly filled Claim form, along with all supporting documents, must be submitted to the Liquidator and received by email, fax, courier or registered mail no later than July 29, 2016, at 5PM.

PRICEWATERHOUSECOOPERS INC.
Liquidator of 9342-8530 Québec inc. (formerly DiagnoCure inc.)
2640, laurier blvd., Office 1700
Québec (Québec) G1V 5C2

Mail to: Monsieur David Labadie
Tel.: 418-522-7001, Ext 2319
Fax: 418-522-5663
Email:

All claim forms must be received by the liquidator on July 29, 2016, by 5PM at the latest, otherwise, you will be presumed to have renounced to all claims against the Company or an administrator and participating within the Claims Process.

In completing the attached form, your attention is directed to the following requirements:

a)The form must be completed by an individual and not by a corporation. If you are acting for a corporation or other person, you must state the capacity in which you are acting, such as, “Credit Manager”, “Treasurer”, “Authorized Agent”, etc.

b)The person signing the form must have knowledge of the circumstances connected with the claim.

c)The debtor’s name and date of the bankruptcy must be filled in and a Statement of Account containing details of the claim must be attached and marked “A”. The date at which claims are to be calculated and the correct name of the debtor may be found on the Notice sent to the creditor.

d)The person signing the form must insert the place and date and the signature must be witnessed.

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