PROOF OF DEBT LODGEMENT

A.C.N. 608 320 092 Pty Ltd (Formerly: Motek Pty Ltd)

Creditor Name

Contact Name

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I am the creditor personally. I 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, unpaid and unsatisfied.

Trading As

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Total Claim Including Security

Claim Description

Reference No

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Do you have security?

Have you obtained judgement?

Was this a default judgement?

Is this debt guaranteed?

I have the following documents (tick as many as applicable):
Invoices

Letter Of Demand

Guarantee

Statements

Orders From Company

Credit Application

Judgement From Court

Statutory Demand