PROOF OF DEBT FORM

DEBT SETTLEMENT ARRANGEMENT (DSA) Ref. S.64 (2) & (3), and First Schedule
to the Bankruptcy Act 1988, paragraphs 1 22
PERSONAL INSOLVENCY ARRANGEMENT (PIA) S.98 (2) & (3), and First
Schedule to the Bankruptcy Act 1988, paragraphs 1 22
1

Debtor Name

ISI Case Reference No.

Court Reference No.

Arrangement Type (DSA or PIA)

Legal Name of Creditor

Trading Name of Creditor

If the Creditor proving the debt

purchased the debt from another
person or corporate entity, or was
transferred the debt by another,
enclose copy of the document
transferring the ownership of the
debt

Address of Creditor

Creditor Tel. No.

10

Creditor Email Address

11

Name of Creditor Contact Person

12

Creditor
Relevant
Account No.

13

Total amount of claim, including

any
Value
Added
Tax
and
outstanding un-capitalised interest
as at the date the Protective
Certificate (PC) was issued by
the relevant Court, along with
copy statements showing the
debt as of the date the PC
issued

Reference

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PROOF OF DEBT FORM

DEBT SETTLEMENT ARRANGEMENT (DSA) Ref. S.64 (2) & (3), and First Schedule
to the Bankruptcy Act 1988, paragraphs 1 22
PERSONAL INSOLVENCY ARRANGEMENT (PIA) S.98 (2) & (3), and First
Schedule to the Bankruptcy Act 1988, paragraphs 1 22
14

Amount of Bank charges included in

Claim

15

Amount of Interest in Claim

16

17

18

Details of any document by

reference to which the debt can be
substantiated. [Note the Personal
Insolvency Practitioner may call
for any document or evidence
to substantiate the claim at
their discretion]
If total amount above includes
outstanding un-capitalised interest,
please state amount
Give details of whether the whole or
any part of the debt falls within any
(and if so which) of the categories
of preferential debts under section
81 of the Bankruptcy Act 1988

19

Particulars of how and when debt

incurred

20

State the particulars and value of

any security held

21

State the date on which security

was given

22

Signature of creditor or person

authorised to act on the creditors
behalf

23

Name of
LETTERS

24

Position with or relation to creditor

25

Date of Proof of Debt Submission

signatory

in

BLOCK

Please return completed and signed Proof of Debt Submission (POD) to

Personal Insolvency Practitioner (PIP) by email or post within the time
period prescribed in the PIPs S.98 Notice.
PIP Name

Mitchell OBrien

ISI PIP Authorisation No.

PC00001

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PROOF OF DEBT FORM

DEBT SETTLEMENT ARRANGEMENT (DSA) Ref. S.64 (2) & (3), and First Schedule
to the Bankruptcy Act 1988, paragraphs 1 22
PERSONAL INSOLVENCY ARRANGEMENT (PIA) S.98 (2) & (3), and First
Schedule to the Bankruptcy Act 1988, paragraphs 1 22
Name of PIP Practice
Address for PIP
PIP Tel. No.
PIP Email Address

Insolvency Resolution Service

Garraunfadda, Dungarvan
Co. Waterford, X35 D653
Within Rep. of Ireland (058) 23511
From outside the Rep. of Ireland +353 58
23511
mitchellobrien.irs@gmail.com

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