FORM E
PROOF OF CLAIM SUBMITTED BY AUTHORISED REPRESENTATIVE OF WORKMEN AND EMPLOYEES
(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 duly authorised representative of the workmen / employees]
Subject: Submission of proofs of claim.
Madam/Sir,
I, [name of authorised representative of the workmen / employees], currently residing at [address of authorised representative of the workmen / employees], on behalf of the workmen and employees employed by the above named corporate debtor and listed in Annexure A, solemnly affirm and say:
1. That the above named corporate debtor was, at the insolvency commencement date, being the ________ day of ______ 20 ___, justly truly indebted to the several persons whose names, addresses, and descriptions appear in the Annexure A below in amounts severally set against their names in such Annexure A for wages, remuneration and other amounts due to them respectively as workmen or/ and employees in the employment of the corporate debtor in respect of services rendered by them respectively to the corporate debtor during such periods as are set out against their respective names in the said Annexure A.
2. That for which said sums or any part thereof, they have not, nor has any of them, 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.]
Deponent
ANNEXURE
1. Details of Employees/Workmen
| S. NO. | NAME OF EMPLOYEE/ WORKMAN | IDENTIFICATION NUMBER (PAN NUMBER, PASSPORT OR AADHAAR CARD) | TOTAL AMOUNT DUE (RS.) | PERIOD OVER WHICH AMOUNT DUE |
| 1 | ||||
| 2 | ||||
| 3 | ||||
| 4 |
2. Particulars of how debt was incurred by the corporate debtor, including particulars of any dispute as well as the record of pendency of suit or arbitration proceedings (if any).
3. Particulars 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.
ATTACHMENTS:
(a) Documents relied as evidence as proof of debt and as proofs of non-payment of debt.
(b) Affidavit in the form set out in this Form E.
I, [Name of claimant], currently residing at [insert address], do hereby declare and state as follows: –
1. [Name of corporate debtor], the corporate debtor was, at the insolvency commencement date, being the……………..day of…………..20……., actually 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 and no material facts have been concealed therefrom.
4. In respect of the said sum or any part thereof, neither I, nor 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].
Date:
Place:
(Signature of the claimant)
I, [Name] the claimant hereinabove, do hereby verify that the contents of this proof of claim are true and correct to my knowledge and belief and no material fact has been concealed therefrom.
Verified at … on this …… day of ………., 20…
(Signature of claimant)
AFFIDAVIT
[PLEASE SUBMIT IF APPLICATION SUBMITTED BY AUTHORISED REPRESENTATIVE ON BEHALF OF WORKMEN / EMPLOYEES]
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 _________________ day, the __________day of__________ 20_____
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