Serial number of the charge in the index

Date of the registration

Number of company

Name of company

Amount secured by

Debenture issued

Date of trust deed relating to debentures

Other charges etc.

Party by whom registered

Names and addresses of persons entitled to the charges or of the trustees for the debenture-holders

Signature of registrar

First issued

Further issues

1

2

3

4

5

6

7

8

9

10

11

12