FORM F
PROOF OF CLAIM BY CREDITORS (OTHER THAN FINANCIAL CREDITORS AND OPERATIONAL CREDITORS)
[Under Regulation 9A of the Insolvency and Bankruptcy Board of India (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 creditor]
Subject: Submission of proof of claim.
Madam / Sir,
I, [Name of the creditor], hereby submit the following proof of claim in respect of the corporate insolvency resolution process in the case of [name of corporate debtor]. The details of the same are set out below:
PARTICULARS
| 1 | Name of the creditor | |
| 2 | Identification number of the creditor (If an incorporated body corporate, provide identification number and proof of incorporation. If a partnership or individual, provide identification record* of all partners or the individuals) | |
| 3 | Address and email address of the creditor for correspondence | |
| 4 | Description of the claim (Including the amount of the claim as at the insolvency commencement date) | |
| 5 | Details of documents by reference to which claim can be substantiated | |
| 6 | Details of how and when the claim arose | |
| 7 | 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 | |
| 8 | Details of: a. any security held, the value of security and its date, or b. retention title arrangement in respect of goods or properties to which the claim refers | |
| 9 | Details of 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 claim in order to prove the existence and non-satisfaction of claim due to the creditor |
Signature of the creditor or any person authorised to act on his behalf
(Please enclose the authority if this is being submitted signed on behalf of the creditor)
Name in BLOCK LETTERS
Position with or in relation to the creditor
Address of the person signing
* PAN, Passport, AADHAAR or the identity card issued by the Election Commission of India.
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)
[Note: In the case of company or limited liability partnership, the declaration and verification shall be made by the director/manager/secretary and in the case of other entities, an officer authorised for the purpose by the entity]
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 for the claim, the value of which amounts to Rupees. [insert amount of claim].
2. In respect of my claim, 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 claim, 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 (if any):
[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