On behalf of: Applicant By: [insert name] No: [insert number] Exhibits: [insert details] Date: [insert date] Filed: [insert date] Court Reference No:[ INSERT COURT REF. NUMBER] [ IN THE HIGH COURT OF JUSTICE BUSINESS AND PROPERTY COURTS [OF ENGLAND AND WALES] [IN [INSERT LOCATION]] [ INSOLVENCY AND COMPANIES LIST (ChD)] OR [IN THE COUNTY COURT AT [INSERT LOCATION]] [BUSINESS AND PROPERTY COURTS LIST] OR [ IN THE HIGH COURT OF JUSTICE [CHANCERY DIVISION [INSERT LOCATION] [ DISTRICT REGISTRY ] In the matter of [Insert company name] And In the matter of the companies act 2006 Statement of [Insert full name] I, [Insert full name], [insert role/job title] of [insert