[See rule 12(1)] CLAIM WITH PROOF BY A CREDITOR [Under rule 12 of the Insolvency and Bankruptcy (Application to Adjudicating Authority for Bankruptcy Process for Personal Guarantors to Corporate Debtors) Rules, 2019] [Date] To The Bankruptcy Trustee [Name of the Bankruptcy Trustee] [Address as set out in public notice] From [Name and address of the creditor] Subject: Submission of claims with proof. Madam/Sir, [Name of the creditor], hereby submits this proof of claim in respect of the bankruptcy process in the case of [name of bankrupt]. The details for the same are set out below:
¹Hkkx IIμ[k.M 3(i)] Hkkjr dk jkti=k % vlk/kj.k 71 S. No. Particulars 1. Title and full name of creditor 2. Identification number of | Aadhar PAN CIN GSTIN creditor 3. Address Present Permanent Business 4. Total amount of claim (Including any interest as at the bankruptcy commencement date) 5. Details of documents by reference to which the debt can be substantiated. 6. Details of any dispute as well as the record of such dispute Note: ‘Dispute’ will include suits, arbitration proceedings, and other judicial proceedings contesting the existence or validity of the debt. 7. Details of how debt was incurred and the date when debt incurred 8. Details of any mutual credit, mutual debts, or other mutual dealings between the bankrupt and the creditor which may be set-off against the claim 9. Details of any retention of title arrangements in respect of goods or properties to which the claim refers 10. Details of the bank account to which the amount of the claim or any part thereof can be transferred pursuant to a repayment plan 11. Details of any security held (including value and date when it was given)
12. For secured creditors only Tick whichever is applicable – □ security interest is being enforced □ Security interest is being relinquished. If security is being I, [name of secured creditor], hereby release and relinquish relinquished, please my security interest and any claim, right, lien or interest in complete the statement of any property based on such security interest, other than the relinquishment of secuirty right to receive dividends as per the Code, in [insert interest in the column on the description of the subject and nature of security interest], right. | which was created by [name of bankrupt], on [insert date of creation of security interest] on account of [insert description of circumstances leading to creation of security interest]. Signature of the secured creditor, or the authorised signatory. If security is being realised, provide details of any action that has been taken to enforce / realise the security. If security is being realised, specify balance amount of debt which is being claimed. 13. List of documents attached to this proof of claim in order to prove the existence and non-payment of claim due to the creditor 14. Details of bank account to which the share of creditor’s proceeds from bankruptcy can be deposited. Signature of creditor or person authorised to act on his behalf [Please enclose the authority if this is being submitted on behalf of a creditor] Name in block letters Address of person signing
¹Hkkx IIμ[k.M 3(i)] Hkkjr dk jkti=k % vlk/kj.k 73 DECLARATION I, [name of claimant], currently residing at [insert address], declare and state as follows: 1. [Name of bankrupt], the debtor was, at the bankruptcy commencement date, being the __________ day of __________ 20__, justly and truly indebted to me to the sum of INR [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 bankrupt and the creditor which may be set-off against the claim.] Date: Place: (Signature of the claimant) VERIFICATION I, [Name], the claimant hereinabove, do hereby verify that the contents of this claim with proof are true and correct to my knowledge and belief and no material facts have been concealed therefrom. Verified at ______ on this _____ day of ____ 201__ (Claimant's signature) [F. No. 30/21/2018-Insolvency Section] GYANESHWAR KUMAR SINGH, Jt. Secy.