Form C

[Under regulation 12 of the Insolvency and Bankruptcy Board of India (Insolvency Professionals) Regulations, 2016] To The Executive Director (IPE Division) Insolvency and Bankruptcy Board of India (IBBI) Subject: Application for recognition as an insolvency professional entity. Sir/Madam, I, having been duly authorised for the purpose, hereby apply, on behalf of [name of the applicant entity], having registered address at [registered address of the applicant], forrecognition as an insolvency professional entity under sub-regulation (2) of regulation 12 of the Insolvency and Bankruptcy Board of India (Insolvency Professionals) Regulations, 2016. The details of the applicant and its directors / partners are as under: A. DETAILS OF APPLICANT 1. Name: 2. Address: i. registered office: ii. principal place(s) of business, if any: 103 Substituted by Notification No. IBBI/2019-20/GN/REG049, dated 25th October, 2019 (w.e.f. 25.10.2019).

iii. Address for Correspondence with the Applicant iv. E-mail address for correspondence with the Applicant: v. Telephone number for correspondence with the Applicant: 3. Nature of constitution: Company /Limited Liability Partnership/ Registered Partnership (strike off whichever is not applicable) 4. Corporate Identification Number (CIN)/ LLP Identification Number (LLPIN)/ Certificate of Registration: 5. PAN: 6. GSTIN (if available): 7. Name, designation and contact details of the person authorised to make this application and correspond with the Board on behalf of applicant: i. Name: ii. Designation: iii. Address for correspondence: iv. Mobile No. / Landline No: v. E-mail address: B. DETAILS OF THE DIRECTORS / PARTNERS OF THE APPLICANT AS ON DATEOF APPLICATION Sl. No. Name of the director/ partner Address of the director/ partner DIN/DPIN (if available) PAN Registration No. as an insolvency professional Professional membership No. (if applicable) % share in shares / capital contributed Whether Whole Time Director (Yes / No) (1) (2) (3) (4) (5) (6) (7) (8) (9) C. ELIGIBILITY [in terms of Regulation 12 (1) of IP Regulations] 1. Sole objective of the applicant as per its constitutional document [Description of the sole objective]: 2. Net worth of the applicant as on ….. (Date should not be earlier than more 90 days from the date of application): (i) Amount: (ii) Date of net worth:

(iii) Unique Document Identification Number of the net worth certificate issued by the Chartered Accountant, if any: (iv) Date of the net worth certificate issued by the Chartered Accountant, if any: 3. Details of shareholding or partner’s contribution in the applicant: (i) In case of Partnership Sl. No. Name of Partner Amount (Rs.) of capital contribution % share in total capital contribution Whether partner is an insolvency professional (Yes / No) Registration No. as an insolvency professional, if applicable (1) (2) (3) (4) (5) (6) (ii) In case of Company Sl. No. Name of Shareholder Number of shares held % of shares held Whether shareholder is a director (Yes / No) Whether shareholder is an insolvency professional (Yes / No) Registration no. as an insolvency professional, if applicable (1) (2) (3) (4) (5) (6) (7) 5. Whether the applicant was at any time in the past derecognised as an insolvency professional entity. (Yes/No) If yes, please furnish the date of derecognition and ground for derecognition. 6. Whether any disciplinary proceeding has been initiated by the Board (IBBI) or the Insolvency Professional Agency against any director(s) / partner(s), who was/is/are insolvency professional(s). (Yes/No) If yes, please provide details. AFFIRMATION I, on behalf of [name of the applicant entity], affirm that - (i) the applicant is eligible to be recognised as an insolvency professional entity; (ii) none of the directors or partners of the applicant, as the case may be, is a director or partner of another insolvency professional entity.

2. I affirm that the information furnished in this application is correct and complete to the bestof my knowledge and belief. 3. I, on behalf of [name of the applicant entity], undertake to comply with the requirements ofthe Insolvency and Bankruptcy Code, 2016, rules, regulations, guidelines and circulars issued thereunder, and such other terms and conditions as may be imposed by the Board while granting the certificate of recognition. Yours faithfully, Authorised Signatory (Name) (Designation) Place: Date: ATTACHMENTS 1. Copy of Board / Partners’ Resolution authorising the person to make this application and make correspondence with the Board 2. Copy of CIN/LLPIN/Certificate of Registration of the applicant 3. Copy of PAN of the applicant 4. Copy of GST Registration Certificate of the applicant 5. Copy of Memorandum of Association/LLP Agreement/Registered Partnership Deed of the applicant 6. Copy of certificate of net worth issued by the Chartered Accountant, if any 7. Copy of Financial Statements of the applicant (including Provisional Financial Statements, as on same date on which net worth of applicant has been submitted) 8. Copy of Certificate of Registration issued by the Board to IPs who are directors or partners, as the case may be, of applicant 9. Evidence of deposit / payment of fee, along with GST, as required under regulation 12(2) of IP Regulations.]