On behalf of: Applicant

By: [insert name]

No: 1

Exhibits: [insert details]

Date: [insert date]

Filed: [insert date]

Court Reference No:[ INSERT COURT REF. NUMBER]

[IN THE HIGH COURT OF JUSTICE

BUSINESS AND PROPERTY COURTS [OF ENGLAND AND WALES] [IN [INSERT LOCATION]]

[ Insolvency AND COMPANIES LIST (ChD)]

OR

[IN THE COUNTY COURT AT [INSERT LOCATION]]

[BUSINESS AND PROPERTY COURTS LIST]

OR

[ IN THE HIGH COURT OF JUSTICE

[CHANCERY DIVISION]

In the matter of [Insert Company name]

And

In the matter of the companies act 2006

Statement of [Insert full name]

I, [Insert full name], [insert role/job title] of [insert company name] of [insert address] Do state as follows:

1. 1. 1

      Introduction

      I am the [insert role or job title] of [insert company name] (the Company), having been appointed on [insert date]. I have been the officer of the Company most closely connected with the proposal that is the subject of this witness statement. The facts and matters to which I refer in this witness statement are either within my own knowledge and are true, or derived