Rule 6.41(1)	Statement of Affairs (Debtor’s Petition)Insolvency Act 1986	Form 6.28
NOTE:	In the
These detailswill be the same as those shown at the top of your petitionPlease complete this form in black ink.	In BankruptcyNo. ________ of   20 _____
(a) Insert full name (b) Insert occupation (c) Insert full address	Re ____________________________________________________________The ‘Guidance Notes’ Booklet tells you how to complete this form easily and correctlyShow your current financial position and supply the required information by completing all the pages of this form, which will then be your Statement of Affairs   AFFIDAVIT When you have completed the rest of this form, this Affidavit must be sworn before a Solicitor or Commissioner for Oaths or an officer of the court duly authorised to administer oaths I (a) __________________________________________________________ _(b)____________________________________________________________ of (c) _________________________________________________________ ______________________________________________________________ ______________________________________________________________ Make oath and say that the several pages marked ______________________________________________________________ and contained in the exhibit marked “Z” are to the best of my knowledge and belief a full, true and complete statement of my affairs at today’s date. Sworn at Dated this ____day of _____________ 20____ Signature(s) ______________ Before me ______________________________________________________   A Solicitor or Commissioner for Oaths or authorised officer Before swearing the affidavit, the Solicitor or Commissioner is particularly requested to make sure that the full name, address and description of the deponent are stated, and to initial any crossing out or other alterations in the printed form. A deficiency in the affidavit in any of the above respects will mean it will be refused by the court, and will need to be re-sworn.

 

 

IN THE                                                           No                 of   20

 

IN BANKRUPTCY

 

 

 

 

 

 

Re

 

 

 

 

 

 

 

This is the exhibit marked “Z” referred to in the annexed affidavit of

 

 

 

sworn on the              day of                                  20

 

 

Before me

 

 

Officer appointed to administer oaths

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 1 :                                             Personal Details

1.1	Surname
	Forename(s)
	Title (Mr, Mrs, Ms etc)
1.2	Any other names by which you have been known (such as maiden name, alias or nickname).
1.3	Date of birth
1.4	Place of birth
1.5	National insurance number
1.6	Home address
1.7	Home telephone number
1.8	Mobile telephone number
1.9	On which telephone number can you be contacted during the day?
1.10	E-mail address
1.11	Are you (tick all that apply):

Single		Co-habiting		A civil partner
Married		Separated		A former civil partner
Divorced		Widowed		A surviving civil partner

1.12

Are you, or in the last 5 years have you been, involved in proceedings for divorce, separation or the dissolution of a civil partnership?

Yes

No

If ‘No’, please go to question 1.14

Section 1 cont:                                        Personal Details

 

If Yes, please give details including any agreed settlement whether formal or informal, and any gifts or transfers of property that occurred in those proceedings.

1.13	Name, address and reference of your solicitor in the proceedings
1.14	Have you been bankrupt before?	Yes	No
	If Yes, when?
	Which court and which Official Receiver’s office dealt with the proceedings?

 

 

1.15	Have you previously entered, or have you tried to enter, into an Individual Voluntary Arrangement (a formal arrangement with your creditors, ratified by the Court, to pay them in full or part over time)?	Yes	No
	If Yes, give the name and address of the insolvency practitioner involved and the date of the arrangement.

Section 1 cont:                                        Personal Details

1.16		Are you involved in any legal proceedings?	Yes		No
	If Yes, please give brief details of the nature of the proceedings, the name and address of any solicitor acting for you, the name of the relevant court and any case or reference number.

1.17	Are you, or in the last five years, have you been a director or involved in the management of a company?	Yes                                        No
	If ‘Yes’, please give details of all the companies in question:
	Name of company If the company is subject to liquidation administration, administrative receivership or other insolvency proceedings, give details of the Official Receiver’s office or insolvency practitioner dealing with the company.

Section 2 :                                        Business Details

 

Please complete this section if you are or have been self-employed (including a partner in a

partnership) at any time in the last two years. If not, go to Section 3.

 

2.1	What was the name of your business?
2.2	State the type of business, trade or profession
2.3	What was the trading address?(this should also be listed in Section 8)
2.4	Was the business registered for VAT?	Yes		No
	If Yes, give the VAT number.
2.5	If the business was a partnership give the name(s) and address(es) of the partner(s)
2.6	When did the business start trading?
2.7	If it has stopped trading, when did it do so?
2.8	At what address are your books of account and other accounting records kept?
2.9	If you hold records on a computer, provide details of which records are held, what software is used (including any passwords) and state where the computer is.
2.10	What is the name and address of your accountant?
2.11	What is the name and address of your solicitor?

 

       

                    

      

 
                          

 

 

 

 

 

 

 

 

 

 

Section 2 cont:                                     Business Details

2.12	Have you employed anybody during the last two years?	Yes		No
	If Yes, do you owe them any money or may any former employee claim that you owe them any money, e.g. for wages, holiday pay or redundancy pay?	Yes		No
		Details of employees to whom money is or may be owing should be included in your list of creditors in Section 4.

3.1	Details (if none owned write “NONE”)	Approximate value £
1. Cash in hand
2. Cash  in bank, building society or similar account
3. Cash held by anyone for you
4. Money owed to you
5. Tools of your trade
6. Stock in trade
7. Machinery, plant and equipment
8. Fixtures and fittings
9. Freehold land and property
10. Leasehold land and property

Section 3:                                                                    Assets

	Details	Approximate value £
11. Stocks, shares and investments
12. Pension policies and other pension entitlements
13. Endowment and other life policies
14. Motor vehicles
15. Farming stock and crops
16. National Savings and Premium Bonds
17. Any property or possessions abroad in which you have an interest, including timeshares
18. Any property or sums due to you under a will or trust
19. Any other property of any value e.g. paintings, furniture or jewellery

Section 3 cont:                                                            Assets

Section 3 cont:                                             Assets

 

3.2

Do you have or have you had any endowment or other life policies?

Yes

No

3.3       If Yes, give details, including details of lapsed policies.

Name and address (including postcode) of life assurance company or broker	Policy number	When was it taken out, roughly?	Type of policy	Estimated value of policy £	Name and address (including postcode) of any concern holding security over the policy
		TOTAL		£   0

3.4

Apart from state benefits, do you have or have you had any personal pension arrangements?

Yes

No

If Yes, give details.

Name and address of the pension company	Policy number	Roughly when did you take out the policy? How much have you paid in total?	When are the payments to you due to start?	Amount (if any) being received now, and how often/period £	Value of pension £

Section 3 cont:                                             Assets

 

3.5       Have you in the last five years given away, transferred

or sold for less than its true value any property or             Yes                               No

possessions you owned? This includes the surrender of

life, endowment and pension policies.

 

If Yes, please provide the following details.

 

Description of the asset	When did you give away, transfer or sell the asset?	Name and address of recipient	Estimated market value or true value of the asset	Value at which the asset was given away, transferred or sold

 

3.6

In the last 2 years have you made any payment to a creditor, other than in the ordinary course of business, with a view to improving the position of that creditor in case you became subject to insolvency/bankruptcy proceedings?

Yes

No

If Yes, give details.

 

3.7       Do you own a motor vehicle or have you disposed of any             Yes                                No

vehicle in the last 12 months? (if you own a motor vehicle,

this should also be listed in Q3.1)

Section 3 cont:                                             Assets

Make/Model
Registration number
Estimated value £
Finance outstanding £
Name of finance company
Reference number of agreement
Does the vehicle have a valid MOT? If yes, provide expiry date of MOT
Insurance / Expiry date
Give your general view on the condition of the vehicle
Location of vehicle
Name of any joint owner

If Yes, please provide  the following

details:

3.8        If you have disposed of any vehicle in the last 12 months, please specify where the vehicle is now.

Section 3 cont:                                                  Assets

3.9       Do you have the use of a motor vehicle                                                 Yes                           No

that you do not own?

Registration number
Owner
Estimated value £

If Yes, please provide the following details:

3.10	Has an enforcement officer (previously known as sheriff’s officer) / bailiff visited you in the last 6 months?(An enforcement officer / bailiff is an officer of the court who may attend to remove assets for sale, if, for example, a judgment debt has not been paid)	Yes                                   No
	If Yes, please provide the following details:

Name of creditor	Amount of claim £	Date distress levied	Description and estimated value of property seized

	Name of creditor	Address	Account, reference or agreement number (if known)	Amount owing (A) £	What of yours is claimed and what is its present value? (B) £		Net amount owing (A-B) £
						TOTAL £

 

Name of creditor	Address		Account, reference or agreement number (if known)	Amount owing £	Date incurred	What was the debt for?
		TOTAL £		0

 

Name of creditor	Address		Account, reference or agreement number (if known)	Amount owing £	Date incurred	What was the debt for?
		TOTAL £		0.00

 

Note: Include any current liability also shown in Section 4.

                                                                                                                          

5.1   Do you have any cheque cards, cash dispenser cards,                                  Yes                              No

credit or charge cards, debit cards, etc?

 

 

5.2   If Yes, provide details.

Type of card	Card number	Name and address of bank or supplier	Date obtained

Yes                             No

5.3   Are any of the above accounts or cards

held jointly with anyone else?

       If Yes, provide details

WARNING:

If you become bankrupt it may be possible for the Official Receiver to ask your bank or building society to release some or all of a credit balance to you if it is required for your domestic living expenses. However you should not access any account without first contacting the Official Receiver.  If you become bankrupt, you must not use any credit cards or charge cards and should cut them in half and send them to the Official Receiver.

 

Note: Include details of accounts with a debit (overdrawn) balance also shown in Section 4.

5.4  Please list any bank, building society or National Savings accounts you hold, or have held in the last two years, including any joint, business or dormant accounts.

Name and address (including postcodes) of banks etc	Account number	Tick if your regular income is paid into this account	Name of joint account-holder (if applicable)	Balance of account £

 

 

The court can order that you pay part of your earnings or other income to your trustee if your income is more than you need to live on. The order is known as an Income Payments Order and is made under section 310 of the Insolvency Act 1986. Alternatively you can enter into a voluntary arrangement with the Official Receiver or trustee called an Income Payments Agreement under section 310A of the Insolvency Act 1986.

 

You must answer the following questions about your income and outgoings and you may be asked to provide your wage slips or salary statements and bills such as gas or electricity to support your answers. This will enable a decision to be made as to whether an Income Payments Order or an Income Payments Agreement is appropriate.

 

The court will not make an Income Payments Order, neither would an Income Payments Agreement be agreed, that would leave you too little income to meet the reasonable domestic needs of you and your family.

 

If an Income Payments Order or an Income Payments Agreement is made against you, the payments will usually stop after 3 years.

 

If your income increases while you are bankrupt, you must inform your trustee of the increase within 21 days.

 

 
 6.1   Are you:                           employed                        self-employed                          unemployed

        If you are unemployed, when did you last

work, what was your last job and who was

your last employer?

6.2     If employed, what is your job and who is

your employer? What is the address of the

personnel department and your pay

reference number?

When did you start this job?

If self-employed, give the name and address

of the business.

6.3

£

What is your average monthly take-home        pay (include, for example, overtime,

commission and bonuses).

£

6.4   How much tax do you usually pay each month?

Section 6 cont:                        Employment and Present Income

£

6.5   How much do you pay in National Insurance        each month?

Yes

No

6.6   Do you receive any other income,

including state benefits or tax credits?

	£

        If Yes, state from what source (for

example pension, state benefits, part-time

earnings) and how much you receive

each month?

£

6.7   How much do other members of your        household contribute each month to

the household expenses?

	£

6.8   Total household income

(Q6.3 + 6.6 + 6.7)

6.9   Give your current (or last)

Income Tax reference number.

Address of tax office

(including postcode)

 

 

 

 

 

 

 

Section 6 cont:                        Employment and Present Income

 

 

6.10	Do you have any current attachment of earnings orders in force against you?				Yes                            No
	If Yes, give details
	Name of creditor	Date of first payment	Date last payment due	Court		Amount of each payment and whether monthly or weekly £	Total amount paid to date £

 

 

 

 

The information in this section may be used to work out how much, if anything, you can afford to pay your creditors each month. It is important that it is accurate and that you include all necessary expenditure.

7.1      How much do you spend each month on the following:-

 

£

         Mortgage payments or rent on         your home

 

£

         Housekeeping (including food         and cleaning)

 

	£

 
         Gas, electricity, other heating

	£

 
         Water

 

	£

 
         Telephone charges

£

Travelling to and from work          and other essential journeys

	£

          Clothing

	£

          Maintenance payments and

fines

	£

          Council tax

£

Other essential payments                                                                                      Provide details of

(e.g. life/household insurance,                                                                             these payments

£

car tax & repairs)                                                         Total                                                                                

 

 

 

 

 

 

 

 

 

Section 8 :                                                                                    Current Property             (including properties used for residential and business purposes)

 

8.1	Give details of any properties you own.(these should also be listed in Q3.1)	Address, type of property (e.g. flat, semi-detached house), number of bedrooms and whether freehold or leasehold	Approximate value of property (A) £	Name and address(es) of any joint owner(s)	Name and address of anyone who holds a charge or mortgage over your property.	Amount owing to each secured creditor (B) £	Net value of the property (A)-(B) £	What insurance is currently in force and what is its  expiry date
							£

 

8.2	Give details of any properties you rent or lease, either alone or jointly.	Address of property	Monthly rent £	Name and address(es) of any joint tenant(s)	Name and address of landlord

You must take or send to the Official Receiver a copy of your lease or rent agreement.

A rent demand or rent book will help if you do not have a copy agreement.

Section 8 cont:                                                                                Current Property

 

8.3	Apart from properties that you own, rent or lease, are there any other properties in

which you may otherwise have an interest?                             Yes

No

If Yes, give details

Address of property, type of property (e.g. flat, semi-terraced) and number of bedrooms

Who lets you use it?

How much do you pay?

Is there a written agreement?

 

8.4

Does anyone else have an interest in any of the properties that you own, rent or lease? This interest may be as a sub-tenant, a guarantor of the mortgage, a partner, a joint tenant, joint lessee or otherwise.

Yes

No

If Yes, give details

Address of property (including postcode)

Name of person with an interest

Their address, if different from the property (including postcode) and reference

Nature of interest

Section 9 :                                           Property Disposed of in the last Five Years

 

9.1	Give details of any properties, owned alone or jointly, that you have sold, given away or transferred in the five years before the presenting of your bankruptcy petition.	Address of property	Value of property £	When did you sell, transfer or give away the property?	To whom did you sell, transfer or give away the property?	Net sale proceeds (less any charges and legal fees) £	Details of solicitor (name and address) who acted on your behalf in the transaction

 

 

10.1   Give the names and ages of all

occupants of your household and

state which, if any, are dependent

on you.

 

 

 

 

 

 

 

 

10.2   Apart from members of your household,                                           Yes                    No

is any other person dependent upon you?    

If Yes, provide details including

their name, address and reason

for dependency

Section 11 :                                     Causes of Bankruptcy

11.1      When did you first have difficulty paying your debts?

11.2      What do you think are the reasons for you not having enough money to pay your debts? You should provide reasons to support your answer. For example, it would not be enough to state “the recession” without explaining its effect on your affairs.

11.3      Have you lost any money through betting or gambling during the last two years?     Yes

               No

If Yes, how much have you lost?

Section 12 :                                                 Declaration

I hereby confirm that my answers to all the above questions (including any extra information on pages following this declaration) are to the best of my knowledge and belief a true and accurate statement of my affairs as at today’s date. I understand that I may be committing a criminal offence if I deliberately give false information in relation to my bankruptcy.

Your signature
Name in BLOCK CAPITALS
Date

Section 13 :                                                Extra Information

Section 13 cont:                                      Extra Information