Form G

[Under Regulation 7(2)(ca) and 13(2)(ca) of the Insolvency and Bankruptcy Board of India (Insolvency Professionals) Regulations, 2016] To The General Manager (IPE Division) Insolvency and Bankruptcy Board of India Subject: Annual statement of services rendered by an insolvency professional entity Sir / Madam, Part A – For services under regulation 7(2)(ca) 1. I, [Insert name], being duly authorised for the purpose, hereby submit the annual statement for the insolvency professional entity [Insert name of the insolvency professional entity] in the financial year [Insert financial year], as under: Sl. No. Name of Corporate Debtor / Guarantor Corporate Identification Number / LLPIN of Corporate Debtor / Identification Number of Guarantor Services rendered as (IRP / RP in a Corporate Insolvency Resolution Process / Authorised Representative in a Corporate Insolvency Resolution Process/ Liquidator / RP in Insolvency Resolution for Individuals/ Bankruptcy Trustee / Other, if any) Amount towards services rendered in the year (In Rs.) 1 2 3 … Total Part B – For services under regulation 13(2)(ca) 2. I, [Insert name], having been duly authorised for the purpose, hereby submit the annual statement for the insolvency professional entity [Insert name of the insolvency professional entity] in the financial year [Insert financial year], as under: Sl. No. Name of Corporate Debtor / Guarantor Corporate Identification Number / LLPIN of Corporate Debtor / Identification Number of Guarantor Name of IP who rendered services as IRP / RP / Liquidator / Bankruptcy Trustee / Other, if any Broad description of kind of service rendered Amount towards services rendered in the year (In Rs.) 107 Substituted by Notification No. IBBI/2022-23/GN/REG097, dated 20th September, 2022 (w.e.f. 01.10.2022).

1 2 3 … Total 3. The following amounts are payable to the Board: SI. No. Under regulation Amount Payable (Rs.) 1 Regulation 7(2)(ca) 2 Regulation 13(2)(ca) 3 Regulation 15, being interest from … to ….. Total 4. A sum of Rs.…, as worked out in Para 3 above, has been deposited into the account of the Board, vide….... 5. I, [insert name], hereby affirm that – (i) all information contained in this statement is true and correct in all material respects and (ii) no material information relevant for the purpose of this statement has been suppressed. (iii) I, [Insert Name], am duly authorised to submit this form on behalf of the insolvency professional entity [Insert name of the insolvency professional entity]. Authorised Signatory (Name) (Designation) (Name of the Insolvency Professional Entity--------) (Recognition Number of the Insolvency Professional Entity----) (Insolvency Professional Registration Number -----------) Place: Date :….] 108