I, ABC, an adult Indian, aged about ____years, Occupation:- ______, Indian inhabitant of ______________, do hereby state on oath and solemn affirmation as under:-

            1] I say that I am as above and I have been staying at the aforesaid address with my family since last several years.

            2] I say that I know one DEF, an adult Indian, aged about ______years, Occupation:-______, Indian inhabitant of __________, since last few years.

            3] I say that I owe a sum of Rs. ______/- (Rs._______only) to DEF on account of a friendly loan, which he had advanced to me a couple of months ago in connection with the purchase of a landed property.

            4] I say that in order to repay the said loan and to clear my liability towards DEF, I have deposited 10 post-dated cheques with him and expressly authorised him to present one cheque every month, starting from _____, 20__ and concluding in ___, 20__. I have solemnly assured him that I will make the necessary arrangements for funds in my bank account and ensure that the said cheques are honoured scrupulously. The details of the said cheques are as follows:

Sr.No. Name of the Bank & Branch Date of cheque Cheque Number Amount      Rs.
1. —–/-
2. —–/-
3. —–/-
4. —–/-
5. —–/-
6. —–/-
7. —–/-
8. —–/-
9. —–/-
10. —–/-

Total:- Rs._____/-

            5] I say that I am well aware of the legal consequences of issuing cheques in favour a party and in the event of their dishonour, I will be liable to DEF to the extent of the said amount.  In such event, DEF shall have the right to institute appropriate legal proceedings against me, including criminal proceedings under section 138 of the N.I. Act r/w section 420 of I.P.C and I hereby bind myself to suffer the consequences of such legal action arising out of the prospective default (if any) on my part.

            6] I say that I have made this declaration in a sound state of mind and body, without being influenced by any sort of coercion or undue influence of whatsoever nature.

            7] I say that whatever is stated hereinabove is true & correct and I believe the same to be true to the best of my knowledge and belief.

Solemnly Affirmed at ____

Dated this___day of_______, 20___

Interpreted, Explained &

Identified by me,


Advocate High Court



Before Me,



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