PROOF OF CLAIM BY ANY OTHER STAKEHOLDER (Under Regulation 19of the Insolvency and Bankruptcy Board of India (Voluntary Liquidation Process) Regulations, 2017) [Date] To The Liquidator [Name of the Liquidator] [Address as set out in the public announcement] From [Name and address of the other stakeholder] Subject: Submission of proof of claim in respect of the voluntary liquidation of [name of corporate person] under the Insolvency and Bankruptcy Code, 2016. Madam/Sir, [Name of the stakeholder] hereby submits this proof of claim in respect of the liquidation in the case of [name of corporate person]. The details for the same are set out below: 1. NAME OF STAKE-HOLDER (IF AN INCORPORATED BODY PROVIDE IDENTIFICATION NUMBER AND PROOF OF INCORPORATION. IF A PARTNERSHIP OR INDIVIDUAL PROVIDE IDENTIFICATION RECORDS* OF ALL THE PARTNERS OR THE INDIVIDUAL) 2. ADDRESS AND EMAIL OF THE STAKEHOLDER FOR CORRESPONDENCE. 3. TOTAL AMOUNT OF CLAIM, INCLUDING ANY INTEREST AS AT LIQUIDATION COMMENCEMENT AND DETAILS OF NATURE OF CLAIM 4. DETAILS OF HOW AND WHEN CLAIM AROSE 5. DETAILS OF ANY MUTUAL CREDIT, MUTUAL DEBTS, OR OTHER MUTUAL DEALINGS BETWEEN THE CORPORATE PERSON AND THE
OTHER STAKEHOLDER WHICH MAY BE SET-OFF AGAINST THE CLAIM 6. DETAILS OF ANY RETENTION OF TITLE IN RESPECT OF GOODS OR PROPERTIES TO WHICH THE CLAIM REFERS 7. DETAILS OF ANY ASSIGNMENT OR TRANSFER OF DEBT IN HIS FAVOUR 8. DETAILS OF THE BANK ACCOUNT TO WHICH THE OTHER STAKEHOLDER’S SHARE OF THE PROCEEDS OF LIQUIDATION CAN BE TRANSFERRED 9. LIST OUT AND ATTACH THE DOCUMENTS BY(i) REFERENCE TO WHICH THE CLAIM CAN(ii) BE SUBSTANTIATED OR WHICH CAN BE RELIED(iii) UPON IN SUPPORT OF THE CLAIM. Signature of stakeholder or person authorised to act on his behalf (Please enclose the authority if this is being submitted on behalf of the other stakeholder) Name in BLOCK LETTERS Position with or in relation to creditor Address of person signing *PAN, Passport, AADHAAR Card or the identity card issued by the Election Commission of India. AFFIDAVIT I, [insert full name, address and occupation of deponent to be given] do solemnly affirm and state as follows: 1. The above named corporate person was, at the liquidation commencement date,that is, the __________ day of __________ 20__ and still is, justly and truly indebted to me [or to me and [insert name of co-partner], my co-partners in trade, or, as the case may be,] for a sum of Rs. __________ for _____ [please state consideration].
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 proof.] 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 have my partners or any of them, nor has any person, by my/our order, to my/our knowledge or belief, for my/ our 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 person and the other stakeholder which may be set-off against the claim.] Solemnly, affirmed at _____________________ 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 para ___ to __of this affidavit are true and correct to my knowledge and belief. Nothing is false and nothing material has been concealed therefrom. Verified at ______ on this ______ day of ______ 201__ Deponent's signature. 39[FORM-G Deposit of Unclaimed Dividends and/or Undistributed Proceeds [Under Regulation 39(5) of the Insolvency and Bankruptcy Board of India (Voluntary Liquidation Process) Regulations, 2017] A. Details of Voluntary Liquidation Process Sl. No. Description Particulars (1) (2) (3) 1 Name of the Corporate Person 2 Identification Number of Corporate Person (CIN/LLPIN) 3 Voluntary Liquidation Commencement Date 39 Ins. by Notification No. IBBI/2019-20/GN/REG054, dated 15th Jan., 2020 (w.e.f. 15.01.2020).
| 4 Date of Deposit into the Corporate Voluntary Liquidation Account 5 Amount deposited into the Corporate Voluntary Liquidation Account (Rs.) 6 Bank Account from which the amount is transferred to Corporate Voluntary Liq uidation Account a. Account No: b. Name of Bank: c. IFSC: d. MICR: e. Address of Branch of the Bank: 7 Details of the Amount (Rs.) deposited into Corporate Voluntary Liquidation Acc ount a. Unclaimed dividends b. Undistributed proceeds c. Income earned till the due date of deposit d. Interest at the rate of twelve per cent on the amount retained beyond du e date (Please show computation of interest amount) Total 40[B. Details of Stakeholders entitled to Unclaimed Dividends or Undistributed Proceeds Sl. Name of Address, Identificati Amount Nature Applicabl Amoun Reason Rema No. stakehold phone non Numberdue to th of Amoe section ot of tax for uncl rks er entitle umber aof the stakeeve unclaiaddress N, CIN, etc. der (Rs.) med dividof the sta) (Please att | unt due f the Incoto be de aimed d to recei nd emailholder (PAstakeholct, 1961 o (Rs.) r any othe | me Tax Aducted dividends or undistri | |
| ndistribut | cation proof | er which t | roceeds |
| ed procee |.) | ax is to be ds | deducted (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) 1 2 3 ] C. Details of Deposit made into the Corporate Voluntary Liquidation Account I (Name of Liquidator) have deposited Rs…… (Rupees ….only) into the Corporate Voluntary Liquidation Account on …. vide acknowledgment no.. … dated …… I (Name of Liquidator) hereby certify that the details provided in this Form are true and correct to the best of my knowledge and belief, and nothing material has been concealed. (Signature) Name of the Liquidator Date:………….. IP Registration No: 40 Substituted vide Notification No. IBBI/2024-25/GN/REG120, dated 28th January 2025, (w.e.f. 29.01.2025). |
5 Debt payable as on Liquidation Commencement date (Amount in Rs.) 6 Net-worth of the Corporate Person (Amount in Rs.) 7 Reasons for initiating voluntary liquidation, in brief 4. Details of realisation during Voluntary Liquidation Process: Sl. No. Particulars Amount (Rs) (1) (2) (3) 1 Sale of Assets 2 Refund from Statutory Authorities 3 Cash / Bank balance 4 Realisation of uncalled/unpaid capital contribution 5 Distribution of unsold asset 6 Any other (Please specify) Total 5. Details of distribution to stakeholders as per section 52 or 53 of the Code (Amount in Rs. lakh)
| Sl. Stakeholders* Amount Amount | Amount | Amount | Remarks |
| No. under section | Claimed Admitted Distributed Distributed 52 and 53 (1) | to the Amount Claimed (%) (1) (2) (3) (4) (5) (6) (7) 1 Realization of Security Interest [Sec. 52(1)(b)] |
2 Liquidation Cost [Sec. 53(1)(a)] 3 Workmen’s Dues [Sec. 53(1)(b)(i)] 4 Debts of Secured Creditors [Sec. 53(1)(b)(ii)] 5 Wages and Unpaid Dues to Employees [Sec. 53(1)(c)] 6 Debts of Unsecured Financial Creditors [Sec. 53(1)(d)] 7 Government Dues + Amount Unpaid following Enforcement of Security Interest [Sec.53(1)(e)] 8 Any remaining Debts and Dues [Sec. 53(1)(f)] 9 Preference Shareholders [Sec. 53(1)(g)]
10 Equity Shareholders [Sec.53(1)(h)] Total *If there are sub-categories in a category, please add rows for each sub-category. 6. The Voluntary Liquidation Process has been conducted as per the stipulated timeline:
| Sl. | Section / | Description of Task Norm | Compliance Actual | |
| No. Regulation | Date | Timeline | ||
| (Number (Number of Days) of days) (1) (2) (3) (4) (5) (6) 1 Section | Declaration from majority of T – 28 59(3)(a), | directors / partners regarding Regulation | solvency of corporate person 3(1) (a) | and it not being liquidated to defraud any person |
| 2 Section | Passing of resolution / special | T = 0 |
59[(3)(c) and resolution by members / (5)], | partners about commencement Regulation | of voluntary liquidation process 3(1)(c) and and appointment of insolvency 3(3) | professional as liquidator
| 3 Proviso to | Approval of creditors | T + 7 | ||||
| Section | representing two-third in value 59(3)(c), | of debt, if the corporate person Regulation | owes any debt, of the resolution 3(1)(c) | passed under section 59(3)(c) or regulation 3(1)(c) | ||
| 4 Regulation | Intimation by Insolvency | T + 7 | ||||
| 5(2) | Professional regarding his appointment as Liquidator, to the Board 5 Regulation 14 Public Announcement in Form | T + 5 (1) | A by the Liquidator 6 Section 59(4), Notification to Registrar of T + 7 or T | |||
| Reg. 3(2) | Companies and Board about the | + 14 | ||||
| resolution passed under section 59(3)(c) and regulation 3(1)(c) or subsequent approval of creditors thereto, as the case may be, by corporate person 7 Section 38(1), Submission of claims by T + 30 Regulation 14 stakeholders (2) 8 Section 38(5) Withdrawal/ modification of T + 44 claim by stakeholders 9 Regulation | Submission of preliminary T + 45 9(1) | report to the corporate person by the Liquidator 10 Regulation | Verification of claims by the T + 60 29(1) | Liquidator 11 Section 40 (2) Intimation about decision of T + 67 acceptance/ rejection of claim to the stakeholders by the Liquidator 12 Regulation | Preparation of list of T + 45*/75 30(2) | stakeholders by the Liquidator |
| 13 Section 42 Appeal by creditor against the T + 81 decision of the Liquidator 14 Regulation | Distribution of the proceeds to Date of 35(1) | stakeholders by the Liquidator realization + 30 15 Regulation | Deposit of amount of unclaimed Prior to 39(2) | dividends and undistributed submission proceeds in Corporate | of Voluntary Liquidation Account application by the Liquidator | under sub- section (7) of section 59 |
| 16 Regulation | Submission of Final Report to | T + | ||||
| 38(2) | the Board and Registrar of 90*/270 Companies by the Liquidator 17 Section 59(7), Submission of Final Report, | T + Regulation | along with the application for 90*/270 38(3) | dissolution, to AA | ||
| 18 Regulation | Completion of Voluntary | T + | ||||
| 37(1) | Liquidation Process | 90*/270 | ||||
| 19 Regulation | Meeting of Contributories and T + 365 37(2) | presentation of Annual Status Report T=Liquidation Commencement Date *Applicable where approval of creditors was not required under section 59(3)(c) or regulation 3(1)(c) 7. The following are deviations / non-compliances with the provisions of the Insolvency and Bankruptcy Code, 2016, regulations made, or circulars issued |
thereunder (If any deviation/ non- compliances were observed, please state the details and reasons for the same):
| Sl. No. | Deviation / Non- compliance | Section of the Code / Regulation No. / Circular | Reasons Whetherrectified or |
| observed | No. | not |
(1) (2) (3) (4) (5) 1 2 3 8. The details of application(s) filed / pending in respect of avoidance of transactions.
| Sl. No. | Type of Transaction Date of Filingwith Adjudicating the Adjudicating | Date of Order of Brief of the Order |
12. Any other information which the Liquidator may like to submit. 13. I [Name of Liquidator], hereby certify that the contents of this certificate are true and correct to the best of my knowledge and belief, and nothing material has been concealed there from. (Signature) Name of the Liquidator: IP Registration No: Address as registered with the Board: Email id as registered with the Board: Date:…………………… Place: ………………….] 42[FORM-I] Withdrawal from Corporate Voluntary Liquidation Account [Under Regulation 39(7) of the Insolvency and Bankruptcy Board of India (Voluntary Liquidation Process) Regulations, 2017] Sl. No. Description Particulars (1) (2) (3) 1 Name of the Corporate Person 2 Identification Number of Corporate Person (CIN/LLPIN) 3 Voluntary Liquidation Commencement Date 4 Date of Dissolution Order 5 Date of Deposit into the Corporate Voluntary Liquidation Account 6 Name of the Stakeholder seeking withdrawal 7 Identification Number of the Stakeholder a. PAN b. CIN/LLPIN/DIN c. Aadhaar No. 8 Address and Email Address of Stakeholder 9 Amount of Claim of the Stakeholder, admitted by the Liquidator 10 Amount of unclaimed dividends / undistributed proceeds deposited by the Liquidator in the Corporate Voluntary Liquidation Account against the stakeholder 42 Substituted by Notification No. IBBI/2022-23/GN/REG.081., dated 5th April, 2022 (w.e.f. 05-04- 2022). Before substitution, it stood as: ““Form-H”.
11 Amount of unclaimed dividends / undistributed proceeds the Stakeholder seeks to withdraw from the Corporate Voluntary Liquidation Account 12 Bank Account to which the amount is to be transferred from the Corporate Voluntary Liquidation Account, if withdrawal is approved (a) Account No.: (b) Name of Bank: (c) IFSC: (d) MICR: (e) Address of Branch of the Bank: 13 Reasons for not taking dividend or proceeds during the Voluntary Liquidation Process 14 Any legal disability in applying for withdrawal? (Yes / No), If yes, please provide details DECLARATION I, [Name of stakeholder], currently residing at [insert address], hereby declare and state as follows: 1. I am entitled to receive a sum of Rs…. (Rupees … only) from the Corporate Voluntary Liquidation Account, as presented above. 2. 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, has received any manner of satisfaction or security whatsoever, save and except the following:............... 3. I undertake to refund the entire amount with interest as decided by the Board, in case the Board finds that I am not entitled to this amount. 4. I authorise the Board to initiate appropriate legal action against me if my claim is found false at any time. Date: Place: (Signature of the Stakeholder) VERIFICATION I, [Name] the stakeholder hereinabove, do hereby verify that the contents of this Form 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 the Stakeholder) [Note: In the case of a company or limited liability partnership, the declaration and verification shall be made by the director/manager/secretary/ designated partner and in the case of other entities, an officer authorised for the purpose by the entity]]