Company No.

10 cm

15 cm

COMPANIES ACT 2016

*Section 484 / *Section 390(2)

AFFIDAVIT VERIFYING STATEMENT OF AFFAIRS

(*WINDING UP BY COURT/*RECEIVERSHIP)

……………………………… (Name of company)

In the matter of the Companies Act 2016

And
In the matter of …………(name of company)

I,…………………. , of…………………………. . I/C No ……………., in the State of …………………….,

being*……………………………. . of…………………………………. (Name of company), make oath and say that the
particulars contained in the statement of affairs relating to……………………. (Name of company) dated the…………day
of………………., 20………., and signed by me are true to the best of my knowledge and belief.

Sworn at…………………………………in
the State of ………………………………
this………………………………………day}
of………………………………., 20……….

Before me-
…………………………………………

* Insert description sufficient to show that the person swearing the affidavit is a person referred to in section 390 (2) or section
484 (2) (as the case requires) of the Companies Act, 2016.

Attention:

It is an offence under section 591 of the Companies Act 2016 to make or authorize the making of a statement that a person
knows is false or misleading and that person may be liable, upon conviction, to imprisonment for a term not exceeding ten
years or to a fine not exceeding RM3million or to both.

LODGER INFORMATION

Name :

NRIC No :

Address :

Phone No :

Email :