Companies.

FORM 23. (rule 39.)

STATEMENT OF AFFAIRS.

(Title.)

STATEMENT OF AFFAIRS on the

day of

19

the date of the winding-up order (or such other date as the Official Receiver has for special reasons directed).

Gross

liabili-

ties.

$

¢

I. As regards Creditors.

Liabilities.

$

Expected

to rank.

$

Assets.

$

Estimated

to

produce.

$

Debts and liabilities, viz-

(a) Unsecured creditors as per List "A" (state number),

(b) Creditors fully secured (not including debenture holders), as per List "B"

Estimated value of securities

$

Estimated surplus $ Carried to List "C"

Balance to con-

tra (d)

$

(a) Property as per List "H", viz-

(a) Cash at bankers

(b) Cash in hand

(c) Stock in trade (Estimated cost, $

)

(d) Machinery

(e) Trade fixtures, fittings, utensils, &c.

(f) Investments shares, &c. in

(g) Loans on mortgage.

(h) Other

viz-

(b) Book debts (debtors), as per List "I", viz-

Good

$

property,

as per List

(c) Creditors partly secured, as per List "C"

Less estimated value of securities

$

Estimated to rank for dividend

$

Doubtful

$

Bad

$4

Estimated to produce..

$

(d) Liabilities on bills discounted other than the company's own acceptances for value, as per List "D"

Of which it is expected will rank for dividend

$

(e) Other liabilities, as per List "E"

Of which it is expected will rank for dividend

$

(f) Preferential creditors for rates, taxes, wages, &c., as per List "F"

deducted

contra (f)

(g) Loan on debenture bonds, as per List "G"

deducted contra (holders)

$

(c) Bills

of exchange, or other similar securities on hand, as per List "J"

Estimated to produce

$

(d) Surplus from securities in the hands of creditors fully secured (per contra)

(b)

$

(e) Unpaid calls (debtors), as per List "K"

$

¢

Estimated to produce

$

Estimated total assets...

Deduct

preferential creditors as per contra (f)

$

Estimated amount available to meet claims of debenture holders

Deduct loans on debenture bonds secured on the assets of the company as per contra (g)

$

Estimated amount available to meet unsecured creditors, subject to cost of liquidation

Estimated deficiency of assets to meet liabilities of the company, subject to cost of liquidation

*

which is

The nominal amount of unpaid capital liable to be called up is $

[available to meet above deficiency] or [charged to debenture holders], or as the case may be.

123

[CAP. 32

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