Regulation 2

(a) Aadhaar No (b) PAN (c) Bank account no, name of the bank, branch to which money is to be remitted and IFSC code 3. Please explain how you have lost money on account of contravention as mentioned under section 220(4) 4. Please show computation of loss suffered by you Verification I hereby verify and affirm that the contents as stated above are true and correct to the best of my knowledge and belief and no material fact has been concealed. (Signature of the Claimant) Note: If the amount of claim exceeds Rs. 10,000, this verification shall be done before a Notary for the purpose of submission of claim.”