Form 4 25 – Fill Out and Use This PDF

Rule 2.72

Form 4.25

PROOF OF DEBT - GENERAL FORM

In the matter of HMV Group Plc

In Administration

and in the matter of The Insolvency Act 1986

Date of Administration 15 January, 2013

1.

Name of Creditor

2.

Address of Creditor

3.

Total amount of claim, including any Value

Added Tax and outstanding uncapitalised

£

interest as at the date the company went into

liquidation (see note)

4.

Details of any document by reference to which

the debt can be substantiated. [Note the

liquidator may call for any document or

evidence to substantiate the claim at his

discretion]

5.

If the total amount shown above includes

Value Added Tax, please show:-

(a) amount of Value Added Tax

£

(b) amount of claim NET of Value Added Tax

£

6.

If total amount above includes outstanding

£

uncapitalised interest please state amount

7.

If you have filled in both box 3 and box 5,

please state whether you are claiming the

amount shown in box 3 or the amount shown

in box 5(b)

8.

Give details of whether the whole or any part

Category

of the debt falls within any (and if so which) of

the categories of preferential debts under

section 386 of, and schedule 6 to, the

Insolvency Act 1986 (as read with schedule 3

to the Social Security Pensions Act 1975)

Amount(s) claimed as preferential £

9.

Particulars of how and when debt incurred.

10.

Particulars of any security held, the value of

the security, and the date it was given

£

11.

Signature of creditor or person authorised to

act on his behalf

Name in BLOCK LETTERS

Position with or relation to creditor

Rule 2.72

Form 4.25