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SCHEDULE
FORM D
PROOF OF CLAIM BY A WORKMAN OR AN EMPLOYEE
(Under Regulation 9 of the Insolvency and Bankruptcy (Insolvency Resolution Process for
Corporate Persons) Regulations, 2016)
[Date]
To
The Interim Resolution Professional / Resolution Professional
[Name of the Insolvency Resolution Professional / Resolution Professional]
[Address as set out in public announcement]
From
[Name and address of the workman / employee]
Subject: Submission of proof of claim.
Madam/Sir,
[Name of the workman / employee], hereby submits this proof of claim in respect of the corporate
insolvency resolution process in the case of [name of corporate debtor]. The details for the same
are set out below:
PARTICULARS
1.
NAME OF WORKMAN / EMPLOYEE
2.
PAN NUMBER, PASSPORT, THE IDENTITY
CARD ISSUED BY THE ELECTION
COMMISSION OF INDIA OR AADHAAR CARD
OF WORKMAN / EMPLOYEE
3.
ADDRESS AND EMAIL ADDRESS (IF ANY) OF
WORKMAN / EMPLOYEE FOR
CORRESPONDENCE
4.
TOTAL AMOUNT OF CLAIM
(INCLUDING ANY INTEREST AS AT THE
INSOLVENCY COMMENCEMENT DATE)
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PARTICULARS
5.
DETAILS OF DOCUMENTS BY REFERENCE TO
WHICH THE CLAIM CAN BE SUBSTANTIATED.
6.
DETAILS OF ANY DISPUTE AS WELL AS THE
RECORD OF PENDENCY OR ORDER OF SUIT OR
ARBITRATION PROCEEDINGS
7.
DETAILS OF HOW AND WHEN CLAIM AROSE
8.
DETAILS OF ANY MUTUAL CREDIT, MUTUAL
DEBTS, OR OTHER MUTUAL DEALINGS
BETWEEN THE CORPORATE DEBTOR AND THE
CREDITOR WHICH MAY BE SET-OFF AGAINST
THE CLAIM
9.
DETAILS OF THE BANK ACCOUNT TO WHICH
THE AMOUNT OF THE CLAIM OR ANY PART
THEREOF CAN BE TRANSFERRED PURSUANT
TO A RESOLUTION PLAN
10.
LIST OF DOCUMENTS ATTACHED TO THIS
PROOF OF CLAIM IN ORDER TO PROVE THE
EXISTENCE AND NON-PAYMENT OF CLAIM
DUE TO THE OPERATIONAL CREDITOR
Signature of workman / employee or person authorised to act on his behalf
[Please enclose the authority if this is being submitted on behalf of an operational creditor]
Name in BLOCK LETTERS
Position with or in relation to creditor
Address of person signing
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AFFIDAVIT
I, [name of deponent], currently residing at [insert address], do solemnly affirm and state as
follows:
1.
[Name of corporate debtor], the corporate debtor was, at the insolvency commencement date,
being the day of 20 , justly and truly indebted to me in the sum of
Rs. [insert amount of claim].
2.
In respect of my claim of the said sum or any part thereof, I have relied on the documents
specified below:
[Please list the documents relied on as evidence of claim]
3.
The said documents are true, valid and genuine to the best of my knowledge, information
and belief.
4.
In respect of the said sum or any part thereof, I have not nor has any person, by my order,
to my knowledge or belief, for my use, had or received any manner of satisfaction or
security whatsoever, save and except the following:
[Please state details of any mutual credit, mutual debts, or other mutual dealings between
the corporate debtor and the creditor which may be set-off against the claim.]
Solemnly, affirmed at [insert place] on
of 20
day, the day
Before me,
Notary/ Oath Commissioner
Deponent's signature
VERIFICATION
I, the Deponent hereinabove, do hereby verify and affirm that the contents of paragraph to
of this affidavit are true and correct to my knowledge and belief and no material facts have been
concealed therefrom.
Verified at on this day of 201
Deponent's signature
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