Page 1
Sensitive (when completed)
NAT 74757-02.2015
Voidable transaction claim
WHO SHOULD COMPLETE THIS FORM?
You should use this form if you are a liquidator making a claim
against the Commissioner of Taxation for payment believed to
be unfair preference payments or uncommercial transactions.
Liquidator name
Contact person phone number
Phone number
Postal address
Suburb/town State/territory Postcode
Section A: Liquidator details
Contact person name
Email
Day Month Year
Date of appointment
Was an administrator previously appointed?
No
Yes
Date of appointment
Day Month Year
Name of firm
Page 2
Sensitive (when completed)
Name
Section B: Entity details
Australian company number (ACN)
Tax file number (TFN)
We are authorised under the Taxation Administration Act 1953 (TAA 1953) to ask for a TFN.
You do not need to provide one. However, if you don’t it may result in a delay in processing your form.
Section C: Director details
Phone number
Address
Suburb/town State/territory Postcode
Name
Phone number
Address
Suburb/town State/territory Postcode
Name
Phone number
Address
Suburb/town State/territory Postcode
Name
Page 3
Sensitive (when completed)
Section D: Summary of liquidator claim
$
,
.
Total claim
Day Month Year
Relation back day
Relation back period
Day Month Year
From
Day Month Year
to
Payments claimed
$
,
.
Amount
Day Month Year
Date
1
$
,
.
2
$
,
.
3
$
,
.
4
$
,
.
5
$
,
.
6
$
,
.
7
$
,
.
8
$
,
.
9
$
,
.
10
$
,
.
11
$
,
.
12
$
,
.
13
$
,
.
14
$
,
.
15
$
,
.
16
$
,
.
17
$
,
.
18
$
,
.
19
$
,
.
20
$
,
.
21
$
,
.
22
$
,
.
23
$
,
.
24
$
,
.
25
$
,
.
Total
If there isn’t sufficient space to list all the payments please insert an additional page detailing the amounts claimed.
0
Page 4
Sensitive (when completed)
Section E: Evidence the Commissioner was preferred
(if an unfair preference claim)
Entity net cash / asset position
Total assets in the liquidation that will be available for distribution to unsecured creditors?
Voidable transaction claims anticipated and for what value?
$
,
.
Value
Priority creditors in this liquidation, including the liquidator fees and costs
$
,
.
Liquidator fees and costs to date
$
,
.
Liquidator fees and costs
to completion (estimated)
$
,
.
Previous liquidator / voluntary
administrator fees and costs
Employee entitlements:
$
,
.
Salary and wages
$
,
.
Superannuation
$
,
.
Other entitlements
$
,
.
SGC liabilities
$
,
.
Other
Are these priority creditors likely to receive a dividend?
No Yes
Ordinary unsecured creditors
List (or attach a list of) all known unsecured creditors as at the date of liquidation,
including those who have proved in the winding up and the amount of their proof.
Basis for determining the transaction was uncommercial (if an uncommercial transaction claim)
Note relevant evidence that the payment was uncommercial.
Page 5
Sensitive (when completed)
Section F: Entity nancial details – in support of insolvency
Financial performance
Relation back date 6 months prior 12 months prior
24 months prior
(foruncommercial
transaction claims)
Date
/ / / / / / / /
Income / Sales
$ $ $ $
Less COGS
$ $ $ $
Gross profit
$ $ $ $
Less expenses
$ $ $ $
Net profit / Loss
$ $ $ $
Did the entity suffer recurring losses?
No Yes
$
,
.
Accumulated losses over a period of
Financial position
Relation back date 6 months prior 12 months prior
24 months prior
(foruncommercial
transaction claims)
Date
/ / / / / / / /
Assets
Current assets
$ $ $ $
Non-current assets
$ $ $ $
Total assets
$ $ $ $
Liabilities
Current liabilities
$ $ $ $
Non-current liabilities
$ $ $ $
Total liabilities
$ $ $ $
Net assets
$ $ $ $
Equity
$ $ $ $
Evidence of insolvency / cash ow
Asset liquidity ratio
(current assets / current liabilities)
Relation back date
:
1 month prior
:
2 month prior
:
3 month prior
:
4 month prior
:
5 month prior
:
6 month prior
:
12 month prior
:
24 months prior
(for uncommercial
transaction claims)
:
Page 6
Sensitive (when completed)
Overdraft facility / overdrawn account
Did the entity have an overdraft facility?
No
Yes
What was the overdraft limit?
$
,
.
Was the overdraft limit exhausted?
No Yes
At the start of the relation back period
How much of the overdraft was used?
$
,
.
Was the overdraft limit exhausted?
No Yes
At the end of the relation back period
How much of the overdraft was used?
$
,
.
$
,
.
How much was overdrawn at the start of the relation back period?
Did the entity have any other accounts (other the overdraft facilities) that were overdrawn?
No Yes
$
,
.
How much was overdrawn at the end of the relation back period?
Debt factoring
Had the entity entered into a debt factoring agreement?
No Yes
Provide details of the factoring firm.
$
,
.
What is the level of debt owing under the factoring facility?
Are those residual debts secured?
No
Yes
Provide details.
What is the value of the residual percentage of debts (if any)?
$
,
.
Interaction with creditors other than the ATO
Consider:
n Did the insolvent entity have arrangements with creditors to pay beyond the due date?
n Did the insolvent entity default on these arrangements?
n Was the insolvent entity put on COD terms with any creditors?
Creditor Arrangements details
Were the terms
honoured? Amount Date of demand Age of debt
$ / /
$ / /
$ / /
$ / /
$ / /
$ / /
Page 7
Sensitive (when completed)
Are you aware of any statutory demands or other demands for payment issued
against the entity by creditors other than ATO?
Creditor Description / Outcome Amount Date issued
$ / /
$ / /
$ / /
$ / /
$ / /
$ / /
Did the entity have any winding up proceedings issued against it by other creditors?
Creditor Description / Outcome Amount Date issued
$ / /
$ / /
$ / /
$ / /
$ / /
$ / /
Is there any evidence that the insolvent entity:
n Had difculties with nancial institutions or secured lenders?
n Failed to obtain additional funds, extend the level of borrowing or renancing?
n Had default notices issued by a secured lender?
n Had a history of dishonoured cheques?
n Had a history of exceeding nance facilities?
Financial institution Date Description
/ /
/ /
/ /
/ /
/ /
/ /
Any other relevant information relating to the claim for unfair preference payment
It is not necessary to provide any information regarding the ATO suspecting insolvency.
Page 8
Sensitive (when completed)
Annexure coversheet
Ensure the documents you have attached are numbered on this coversheet and are clearly labeled.
Documents attached
Annexure Document
Court documents and affidavit material filed by the liquidator
Bank statements of the insolvent entity, including a copy of the front page of a statement
Evidence of third party payments, with evidence that the insolvent entity authorised the
payment and relationship the third party had with the insolvent entity
Cheque butts, cash receipts or other evidence of the source of payments
Aged creditors listing / creditors listing
Proofs of debts lodged by creditors
Statements of financial performance (profit and loss statements)
Statements of financial position (balance sheets)
Evidence of special arrangements with creditors
Demands from creditors
Dishonoured cheques
Report to creditors or letters to creditors from the liquidator
Insolvency report from the liquidator (if available)
RATA completed by the directors
Other correspondence to the ATO from the liquidator
Any other relevant evidence (list)
What we do not need
We do not need any information regarding the interaction between the Entity and the ATO which is already available to us,
forexample:
n case notes
n copies of tax returns
n copies of activity statements
n insolvency report (unless already prepared)
n copies of Running Balance Accounts or Statements of Account
n any correspondence between the entity and the ATO.
Page 9
Sensitive (when completed)
Declaration
Privacy
The ATO is authorised by the Taxation Administration Act 1953 to request the provision of tax file numbers (TFNs). We will use the
TFNs to identify you in our records. It is not an offence not to provide the TFNs. However, if you do not provide your TFN, there may
be a delay in processing this form.
Taxation law authorises the ATO to collect information and to disclose it to other government agencies. For information about your
privacy go to ato.gov.au/privacy
I declare that:
n I am the representative of the incapacitated entity or am authorised by the representative of the incapacitated entity to complete
this form on their behalf
n the information given on this form is true and correct to the best of my knowledge.
Sign and date below if you are sending by fax or post
Day Month Year
Date
Submitting your form
Make a copy of your completed form for your own records before you do one of the following.
Business Portal
Send the documents as an attachment to a secure message under the insolvency subject in the Business Portal.
You must have a valid AUSkey to submit this form via secure messaging in the Business Portal. Your AUSkey is your electronic
signature. By submitting the completed form via the Business Portal, you declare that the information given on the form is true
andcorrect to the best of your knowledge.
Fax or mail
Complete and attach the debt insolvency cover sheet available on our website at ato.gov.au/insolvencycontact and send
yourdocuments to us by either:
n fax on 1300 726 594
n mail to
Australian Taxation Office
PO Box 9003
Penrith NSW 2740
Save form
Reset form
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome