The Board shall periodically disclose summary statistics about receipt and disposal of

grievances and complaints on its web site. 17[***] 17 Substituted by Notification No. IBBI/2026-27/GN/REG144, dated 01st June, 2026 (w.e.f. 03-06-2026). Before substitution, the words stood as under: - “Form A [Under sub-regulation (3) of regulation (3) of the Insolvency and Bankruptcy Board of India (Grievance and Complaint Handling Procedure) Regulations, 2017] Date ………. To Insolvency and Bankruptcy Board of India (Write here the address of the Board) Dear Madam / Sir, Subject: Complaint against [name of the service provider / associated person] I, hereby submit a complaint against [name of the service provider / associated person]. The details of the same are set out as under: Sl. No. Particulars Description 1 Name of the complainant 2 Identity of the complainant Aadhaar No / CIN 3 Name of the authorised representative, if complaint is filed on behalf of the complainant 4 Identity of the authorised representative Aadhaar No. 5 Complete address for correspondence with complainant / authorised representative: (Along with Email ID & Phone No.) 6 Name of the service provider / its associated persons complained against 7 Identity of the service provider Aadhaar No / CIN (If known) 8 Complete address of the service provider (Along with Email ID & Phone No) 9 Details of the alleged contravention of any Please quote the exact section, sub-section, provision of the Code or rules, regulations, or rules, regulation, or clause, as the case may guidelines made thereunder or circulars or be. directions issued by the Board by a service provider or its associated persons.

10 Details of alleged conduct or activity of the Please narrate details. service provider or its associated persons, along with date and place of such conduct or activity, which contravenes the provision of the law. 11 Details of suffering, whether pecuniary or otherwise, the complainant has undergone. 12 How the conduct or activity of the service provider or its associated persons has caused the suffering of the complainant or to any other stakeholder. 13 Details of evidence in support of alleged contravention. 14 Does the complainant have a grievance? If so, how it may be redressed? 15 Is complaint being filed within forty-five days of the occurrence of the cause of action for the complaint? If not explain the reasons for delay. 16 Whether the fee of Rs.2500 has been paid Yes / No 17 The Bank account No. and details of the complainant to which the fee can be refunded 18 Whether the complainant wishes to keep its | Yes / No. identity confidential 19 List of documents attached in support of the | a. Authorisation, if it is filed by an complaint: | authorised representative; b. Demand draft for Rs.2500 / Online acknowledgement of credit of Rs.2500 to the account of the Board; c. d. . . m. n. 20 Any other details in support of the complaint. Yours faithfully Signature Name of the Complainant / Authorised Representative Verification I,................................................., the complainant / authorised representative of the complainant do hereby declare that what is stated above is true to the best of my knowledge and belief. Verified today, the ……………………. day of ………………, 20xx, at …………………… Signature Name of the Complainant / Authorised Representative Date: Place: ”