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Submit a Proof of Debt as a creditor of an institution under KDIC receivership or liquidation — Insolvency Act Form No. 5.

Before You Submit

This form is for creditors of institutions currently under KDIC receivership or liquidation only. Please confirm all of the following apply to you:

The institution is listed under active KDIC receivership or liquidation
You are a legitimate creditor with a provable claim against the institution
Your claim has not already been adjudicated or settled by KDIC
You have supporting documentation available (bank statements, contracts, invoices)

Check institutions under KDIC administration

Proof of Debt — Form No. 5

Complete all required fields below. KDIC will acknowledge receipt and contact you regarding next steps.

Court & Case Reference

Form No. 5 · R. 15(2)(b) · The Insolvency Act · In the High Court of Kenya

Insolvency Cause No.

Year

RE: (Debtor Name)

t/a: (Trading As)

Order Type

Order Date

Of … Petition

Estate No.

Name of Debtor

Name of Debtor * (In case of a partnership, insert full names of all partners)

Creditor Details

Name of Creditor *

Postal Address *

Fax

Telephone *

Email Address *I do not want email communication (email will be used for correspondence by default)

Debt Statement

I, * (Name of person making this declaration)

…state that as at the date of bankruptcy / Summary Instalment Order / Liquidation Order, the debtor was indebted to the above-named creditor for the sum of:

Amount in Words *

Total of Your Claim (Kshs.) *

Security / Guarantee

That security for the payment of the whole or any part of the above amount is not heldThe following security or guarantee is held for the payment of the whole or any part of the above amount

Dividend Payment — Electronic Transfer

If you wish to receive any dividend payments by electronic transfer, please provide the following information.

Account Name

Bank Code

Branch

Account Number

Suffix

Details of Debt

Please attach supporting evidence (invoices, bank statements, contracts, etc.).

Date of SupplyDescription of Goods or Services SuppliedAmount (Kshs.)

Date of Supply

Description

Amount (Kshs.)

Calculated TotalKshs. 0.00

Reference Number (e.g. account number — for correspondence)

Interest

Does your claim include interest?

YesNo

Declaration & Signature

*Any personal information collected is for the purposes of administering the insolvent estate. The information will be used and retained by the Official Receiver/Supervisor and will be released to other parties only with your authorisation or in compliance with the Insolvency Act 2015 / the Companies Act 2015 or the corresponding Regulations. You may have access to and request correction of any personal information. You are obliged to provide this information under the Insolvency Act 2015 / Companies Act 2015.

Date *

I/We, the undersigned, declare that the information provided above is true and correct to the best of my/our knowledge. I/We understand that providing false information in a Proof of Debt is an offence under the Insolvency Act, 2015. *

Fields marked * are required.

After Submission

What Happens Next

Here is the process after you submit your Proof of Debt to KDIC.

Submission Acknowledged

KDIC will send an automated acknowledgement to your email address with a unique reference number within 24 hours of submission.

Documentation Request

KDIC may contact you to provide supporting documents — bank statements, contracts, invoices, or other evidence of the debt.

Adjudication

Your Proof of Debt is reviewed by KDIC's legal and insolvency team. Valid claims are admitted to the creditor register.

Distribution

Admitted claims are paid from the institution's realised assets in the priority order established by the Insolvency Act, 2015.

Legal Basis

This Proof of Debt form corresponds to Form No. 5 under the Insolvency Act, 2015. Creditor claims are adjudicated in accordance with the Kenya Deposit Insurance Act, 2012 and the Insolvency Act, 2015. All submissions are treated as statutory declarations — providing false information is a criminal offence.

Contact KDIC

Questions about your creditor claim?

Contact KDIC's Legal & Insolvency team for assistance with creditor claims, documentation requirements, or the adjudication process.

+254 709 043 000|customercare@kdic.go.ke