FORM 78

Companies Act, 1965

Section 291

STATUTORY DECLARATION AS TO PROOF OF DEBT:

EMPLOYEES GROUP FORM
...................................................... (NAMA SYARIKAT)
In the matter of the Companies Act, 1965
and
In the matter of ...................................... (Nama Syarikat)
I, ......................................................, of ...................................................... I/C No ...........................,
in the State of ...................................................... do solemnly and sincerely declare:
1. That this proof of debt is made on behalf of all the persons specified in the Schedule
endorsed on this statutory declaration, being employees of the above-mentioned
company.
2. That the above-mentioned company was, on the ........................... day of ..........................,
20..............., and still is justly and truly indebted to each person whose name, address and
description appears in the Schedule endorsed on this statutory declaration in respect of
wages due to the person as an employee of the company for services rendered by him to
the company during the periods and in the amount set out against his name in that
Schedule.
3. That none of the persons referred to in the Schedule endorsed on this statutory
declaration has to my knowledge and belief received any manner of satisfaction or security
for the amount or any part of the amount due in respect of wages set out against his name
in that Schedule.
And I make this solemn declaration conscientiously believing the same to be true, by virtue of the
provisions of the Statutory Declarations Act, 1960.
Declared at ........................................ in the State
of ........................................ this .................... day
of ........................................, 20..........
Before me..............................................................................
SCHEDULE
No.

Full Name

Address

Description

Period for which

Wages Due

Amount Due
RM

sen

.................................................
(Signature of declarant)