PROOF OF UNSECURED CLAIM

(Caption and Title)

CLAIM

________________________, Filipino, of age, and a resident of _______________, after

having sworn to in accordance with law, depose and say that:

1. The insolvent debtor __________________, was and still is, at and before the
time of the filing of the petition for insolvency against him, justly and truly indebted to the
undersigned in the sum of ____________________ PESOS (₱ ______________);

2. This debt is in the nature of _____________________;

3. Said debt is unsecured;

4. There are no set-offs or counterclaims against the subject debt;

5. No part of the debt has been paid;

6. Said debt is not barred by the statute of limitations and is provable against the
estate of the insolvent.

(Venue, date, signature)

(Verification)