PETITION BY DEBTOR TO BE ADJUDGED AN INSOLVENT

In the Court of District Judge of	
Insolvency Case No	of	
Exparte—The debtor
In the matter of debtor's 
petition for insolvency, under 
s. 13(1) of the Provincial Insolvency Act
The humble petition of AB residing
At_________and lately of___
(give address where debts were incurred)
Most Respectfully Sheweth:
1.	That the applicant, who is ordinarily living and residing (or carrying on business, or personally working for gain, or in custody) at	 having been unable to pay his debts exceeding Rs. 500 prays for an order of adjudication against him in the circumstances hereunder mentioned.
2.	That on or about the	day of	the applicant was arrested and committed to prison at	in execution of a decree for Rs	dated	made in suit No	of	 (v) under order dated	,. made by	 or (as the case may be) the movable and immovable property of the applicant such as (give short particulars) have been attached and the said attachment is still subsisting.
3. The amount and particulars of all pecuniary claims against the applicant, together with the names and residences of his creditors, are as follows:
4. The following are the particulars of debts and claims outstanding against the applicant.
Names, addresses and occupation of the creditors, particulars of the amounts due and securities.
5. The following are the particulars of the property belonging to the applicant and their respective values.
Household furniture, utensils, etc., all worth about	One house at worth about	
The whole of the above property, which is situate at, etc., has been truly described, and the applicant is willing to surrender and put them entirely at the disposal of this court.
The applicant prays that the court may be pleased to adjudge him insolvent.
Verification
I, AB son of	 aged about	years
by occupation service residing at	do hereby solemnly affirm and say as follows:
I am the petitioner No. 1 above-named and I know and I have made myself acquainted with the facts and circumstances of this case.
The statements in paragraphs 1 to 5 are true to my knowledge and belief.
I sign this verification on this	day of	at the
Court House at	
Before me	Signature of AB
Notary	Signature of Advocate