STATEMENT OF CLAIM

To The Respondent: RESPONDENT_NAME

The Claimant CLAIMANT_NAME claims the amount of $CLAIM_AMOUNT, particulars of the grounds for which and the manner in which it is calculated are set out as follows:

The grounds for the claim are:  (Set out sufficient particulars to inform the Respondent of the grounds for the claim.)

1. At when/which period the Claimant(s) & the Respondent(s) entered into an agreement/arrangement (also state the relationship between the parties)

 ARRANGEMENT_PERIOD

2. What are the arrangement / agreement details? 

 ARRANGEMENT_DETAILS

3. And what happened? 

 ARRANGEMENT_OUTCOME

4. What are the details of the claim? 

CLAIM_DETAILS

The amount of claim is calculated as follows:

Invoice issued date: (if applicable) INVOICE_DATE

Invoices Nos.: (if applicable)  INVOICE_NUMBER                   

Claim amount calculation: (How the amount is calculated and whether it includes any interest or expenses.)

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