ANNEX II

BG ПРЕДЯВЯВАНЕ НА ВЗЕМАНИЯ
ES PRESENTACIÓN DE CRÉDITOS
CS PŘIHLÁŠKA POHLEDÁVKY
DA ANMELDELSE AF FORDRINGER
DE FORDERUNGSANMELDUNG
ET NÕUETE ESITAMINE
EL ΑΝΑΓΓΕΛIΑ ΑΠΑΙΤΗΣΕΩΝ
EN LODGEMENT OF CLAIMS
FR PRODUCTION DE CRÉANCES
GA TAISCEADH ÉILEAMH
HR PRIJAVA TRAŽBINA
IT INSINUAZIONE DI CREDITI
LV PRASĪJUMU IESNIEGŠANA
LT REIKALAVIMŲ PATEIKIMAS
HU KÖVETELÉSEK ELŐTERJESZTÉSE
MT TRESSIQ TA' PRETENSJONIJIET
NL INDIENING VAN SCHULDVORDERINGEN
PL ZGŁOSZENIE WIERZYTELNOŚCI
PT RECLAMAÇÃO DE CRÉDITOS
RO DEPUNEREA CERERILOR DE ADMITERE A CREANȚELOR
SK PRIHLÁŠKA POHĽADÁVOK
SL PRIJAVA TERJATEV
FI SAATAVIEN ILMOITTAMINEN
SV ANMÄLAN AV FORDRINGAR

(Paragraphs 1 to 3 of Article 55 of Regulation (EU) 2015/848 of the European Parliament and

of the Council of 20 May 2015 on insolvency proceedings – OJ L 141, 5.6.2015, p. 19)

I hereby refer to the insolvency proceedings indicated below and lodge my claim(s)
against the insolvency estate, as follows:

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 GUIDELINES FOR FILLING IN THIS FORM:

This standard claims form should be used for lodging claims in accordance with
Chapter IV of Regulation (EU) 2015/848 on insolvency proceedings. Requests to exclude
goods from the debtor’s assets should be filed according to national law.
The use of this standard claims form for the lodgement of claims is optional.
Nonetheless, when lodging claims by means other than this standard form, the claim
must contain all the information referred to as mandatory in this form.

Language
Claims may be lodged in any official language of the institutions of the European Union.
Irrespective of this, you may later be required to provide a translation in the official language
of the Member State of the opening of proceedings or, if there are several official languages in
that Member State, in the official language or one of the official languages of the place where
insolvency proceedings have been opened, or in another language which that Member State
has indicated it can accept (the languages indicated by the Member States are to be found
here: [https://e-justice.europa.eu/content_insolvency-447-en.do?clang=en (1)]
Whenever you refer to a Member State in filling in this form, please use the following
country codes: Austria (AT) Belgium (BE) Bulgaria (BG) Cyprus (CY) Czech Republic
(CZ) Germany (DE) Estonia (EE) Greece (EL) Spain (ES) Finland (FI) France (FR) Croatia
(HR) Hungary (HU) Ireland (IE) Italy (IT) Lithuania (LT) Luxembourg (LU) Latvia (LV)
Malta (MT) Netherlands (NL) Poland (PL) Portugal (PT) Romania (RO) Sweden (SE)
Slovenia (SI) Slovakia (SK) United Kingdom (UK)
When you fill in a particular section of the form, please bear in mind the following:
 The provision of information in points marked with an asterisk (*) is mandatory!
 The provision of information in points marked with double asterisks (**) is
mandatory subject to a condition. This condition is indicated in brackets in
point concerned.
 The provision of information in points without any specific marking is not
mandatory.
If you have several claims to lodge at the same time, you must fill out points 6 to 10 for each
claim individually.
You may find relevant information for points 1 and 2 in Section I of the form by which
you were notified of the foreign insolvency proceedings. That form bears the heading “notice
of insolvency proceedings” and was sent to you by the foreign court which opened the
insolvency proceedings, or by an insolvency practitioner appointed by that court to the
proceedings.

1
When using this form, please, always refer to the hyperlink actually leading to the relevant webpage of the
European e-Justice Portal

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 In point 1.1 "the court opening proceedings" means the judicial body or any other
competent body of a Member State empowered under its domestic law to open insolvency
proceedings, to confirm such opening or to take decisions in the course of such proceedings.
Point 1.2 should be filled in only if the insolvency proceedings have a reference number in
the Member State where they have been opened. Point 1.3 should be filled in only if there is
an insolvency practitioner appointed to the case.
In points 2.2 and 3.3 "registration number" means the individual identity number attached
under national law to the entity or person. If the debtor is a company or a legal person, this is
the number given in the appropriate national (business or association) register. If the debtor is
a natural person exercising an independent business or professional activity (entrepreneurs),
this is the identification number in the Member State where insolvency proceedings have been
opened, under which he/she pursues his/her business or professional activity. If, according to
the national insolvency law of the Member State where insolvency proceedings have been
opened, the tax number or personal ID number of the debtor is used for the purpose of the
identification of the natural person exercising an independent business or professional
activity, this number should be indicated.
In point 4 you should mark the first option referring to the person which the creditor indicated
in point 3 only if the creditor is a natural person. If you mark the second option referring to a
person different to the one indicated in point 3, you are supposed to fill in points 4.1 to 4.6, of
which points 4.1, 4.2 and 4.6 are mandatory fields.
In point 6.2 "the date on which the claim arose" means the point in time on which the
obligation of the debtor vis à vis the creditor was established (conclusion of a contract,
occurrence of a damage or injury). In point 6.3 "the date on which the claim became due"
means the point in time when the debtor was required to perform on the basis of the obligation
(the payment became due). Statutory penalties for late payment which are to be calculated
as a percentage of the capital amount claimed should be asserted as statutory interest (see
point 6.1.3).
In point 7 If you have a preferential position you are owed debts which, according to
domestic law, are to be paid in preference to certain other categories of debt. In point 8,
security in rem refers to any security you hold in respect of your claim against the debtor.
Such security may take several different forms such as a fixed charge on a specific asset or a
floating charge over a group of assets.
In point 9, with regard to set-off, if the creditor is a financial institution and demands set-off
against the debtor, it should also indicate the details of the accounts concerned. Points 9.1 to
9.5 should be filled in only if you demand a set-off.
Point 10: the form must be accompanied by copies of any supporting documents.

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 ANNEX II

1. THE INSOLVENCY PROCEEDING CONCERNED:

1.1. Name of the court opening insolvency proceedings*:

1.2. Reference number of the case (to be filled in if there is any):**

1.3. Name of the insolvency practitioner(s) appointed in the proceedings (to be filled in if
there are any):**

2. DEBTOR:
2.1. Name*
2.1.1. Name (if the debtor is a company or a legal person):
or
2.1.2. Surname:
2.1.3. First name(s):
(if the debtor is a natural person)

2.2. Registration number (to be filled in if there is one under the national law in the
Member State where the debtor has its centre of main interests):**

2.3. Address (unless point 2.4 applies)**:

2.3.1. Street and number/PO box:
2.3.2. Place and postal code:
2.3.3. Country:

2.4. Date and place of birth (to be filled in if the debtor is a natural person and his/her
address is protected):**

Points marked with *: the provision of information is mandatory.

Points marked with **: the provision of information is mandatory subject to a condition.
Point without any specific marking: the provision of information is facultative/optional.

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 ANNEX II

3. INFORMATION ABOUT THE CREDITOR WHO OWNS THE CLAIM(S):

3.1. Name*:
3.1.1. Name:
3.1.2. Legal representative:
(if the creditor is a company or a legal person)
or
3.1.3. Surname:
3.1.4. First name(s):
(if the creditor is a natural person)

3.2. Postal address*:

3.2.1. Street and number/PO box:
3.2.2. Place and postal code:
3.2.3. Country:

3.3. Personal identification number or registration number (if either applies):

3.4. Contact person

3.4.1. Name (if different from you):
3.4.2. E-mail address:
3.4.3. Telephone number:

3.5. Reference number of the creditor:

4. INFORMATION ABOUT THE PERSON WHO IS LODGING THE CLAIM IN THE NAME OF THE
CREDITOR IN POINT 3:

□ the same person as indicated in point 3;

or

□ a different person from the creditor indicated in point 3, whose details are the
following:

Points marked with *: the provision of information is mandatory.

Points marked with **: the provision of information is mandatory subject to a condition.
Point without any specific marking: the provision of information is facultative/optional.

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 ANNEX II

4.1. Name*:

4.2. Postal address*:

4.2.1. Street and number/PO box:
4.2.2. Place and postal code:
4.2.3. Country:

4.3. E-mail address:

4.4. Telephone number:

4.5. Fax:

4.6. His/her relationship to the creditor indicated in point 3*:

□ lawyer (on the basis of a power of attorney); or

□ director of the creditor or other representative of the creditor legally authorized by

the applicable company law; or
□ employee of the creditor; or

□ association for the protection of the creditors; or

□ insolvency practitioner appointed in territorial/secondary proceedings; or

□ insolvency practitioner appointed in a main proceeding; or

□ other (please, specify):

5. DETAILS OF THE BANK ACCOUNT TO WHICH ANY DISTRIBUTION ON THE BASIS OF THE
CLAIMS LODGED SHOULD BE TRANSFERRED:

5.1. Account holder’s name:

5.2. Member State where the account is maintained (please indicate the country code):

Points marked with *: the provision of information is mandatory.

Points marked with **: the provision of information is mandatory subject to a condition.
Point without any specific marking: the provision of information is facultative/optional

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 ANNEX II

5.3. account number:

5.3.1. IBAN:
5.3.2. BIC:

6. THE CLAIM LODGED :

6.1. Amount of the claim*:

6.1.1. Principal*:
6.1.2. Is interest claimed?*
□ No

□ Yes
6.1.3. If yes, is the interest:
□ Contractual interest or

□ Statutory interest
If statutory, to be calculated in accordance with (please specify relevant
statute):

6.1.4. Interest due from: (date (dd/mm/yyyy) or event)

to (date (dd/mm/yyyy) or event).

6.1.5. Interest rate

6.1.5.1. … % from (date) to (date)
6.1.5.2. … % from (date) to (date)
6.1.5.3. … % from (date) to (date)

6.1.6. The capitalized amount of the interest:

6.1.7. Total amount of the claim (point 6.1.1 + point 6.1.6)*:

Points marked with *: the provision of information is mandatory.

Points marked with **: the provision of information is mandatory subject to a condition.
Point without any specific marking: the provision of information is facultative/optional

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 ANNEX II

6.1.8. Currency*:
□ Euro (EUR) □ Bulgarian lev (BGN) □ Czech koruna (CZK) □ Croatian kuna
(HRK) □ Hungarian forint (HUF) □ Polish zloty (PLN) □ Romanian leu (RON) □
Swedish krona (SEK) □ United Kingdom pound (GBP) □ Other (please specify
using the ISO code):

6.2. The date on which the claim arose*:

6.3. The date on which the claim became due (if different from point 6.2):

6.4. Costs that arose from the assertion of the claim prior to the opening of insolvency
proceedings (to be filled in if claimed)**:
6.4.1. amount of such costs:
6.4.2. details of the costs:

6.4.3. Currency:
□ Euro (EUR) □ Bulgarian lev (BGN) □ Czech koruna (CZK) □ Croatian kuna
(HRK) □ Hungarian forint (HUF) □ Polish zloty (PLN) □ Romanian leu (RON)
□ Swedish krona (SEK) □ United Kingdom pound (GBP) □ Other (please
specify using the ISO code):

6.5. Nature of the claim*:

□ the claim relates to a contractual obligation of the debtor

□ liability of the debtor resulting from a willful, tortious act

□ arises from other non-contractual obligation

□ relates to a right in rem of the creditor

□ [outstanding statutory maintenance arrears that the debtor, in breach of his duty,
has intentionally not paid]
□ claims resulting from a contract of employment

□ tax claim

□ claims with regard to contributions to social security bodies

□ other (please specify)

Points marked with *: the provision of information is mandatory.

Points marked with **: the provision of information is mandatory subject to a condition.
Point without any specific marking: the provision of information is facultative/optional.

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 ANNEX II

7. DO YOU CLAIM A PREFERENTIAL POSITION*

□ no

□ yes
if yes, please, specify:

8. DO YOU CLAIM
□ any security in rem;

□ any reservation of title;

□ any other right granting separate satisfaction from certain items of the debtor?

8.1. description of the assets covered by the security, by the reservation of title or by the
other right granting separate satisfaction invoked:

8.2. the date on which the charge, mortgage, other security (please specify), the
reservation of title or the other right granting separate satisfaction was formally
given:

8.3. If the security, the reservation of title or the other right granting separate satisfaction
has been registered with an appropriate public authority, the date and location of
registration and any number with regard to registration:*

9. DOES THE DEBTOR HAVE A CLAIM AGAINST YOU (THE CREDITOR) WHICH MAY RESULT
IN A SET OFF?*:

□ yes (in this case, please indicate the details below)

□ no
9.1. Amount of the claim of the debtor which may result in set-off against the creditor on
the date when insolvency proceedings were opened:

9.2. The date on which the claim of the debtor in point 9.1 arose:

Points marked with *: the provision of information is mandatory.

Points marked with **: the provision of information is mandatory subject to a condition.
Point without any specific marking: the provision of information is facultative/optional.

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 ANNEX II

9.3. The amount claimed net of set-off ( points 6.1.7 to 9.1):

9.4. Currency:
□ Euro (EUR) □ Bulgarian lev (BGN) □ Czech koruna (CZK) □ Croatian kuna (HRK) □
Hungarian forint (HUF) □ Polish zloty (PLN) □ Romanian leu (RON) □ Swedish krona
(SEK) □ United Kingdom pound (GBP) □ Other (please specify using the ISO code):

9.5. Identification of the debtor’s claim against which the creditor demands set-off:

10. LIST OF COPIES OF SUPPORTING DOCUMENTS ENCLOSED:

I declare that the information provided in this application is true and complete to the best
of my knowledge.

Done at ……………………………………., date ……………………………...

Signature………………………………………..…………………………………

Points marked with *: the provision of information is mandatory.

Points marked with **: the provision of information is mandatory subject to a condition.
Point without any specific marking: the provision of information is facultative/optional.

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