Form B

CLAIM WITH PROOF BY A CREDITOR (Under regulation 7(1) of the Insolvency and Bankruptcy Board of India (Insolvency Resolution Process for Personal Guarantors to Corporate Debtors) Regulations, 2019) [Date] To [Name of the Resolution Professional] [Address as set out in public announcement] From [Name and address of the creditor] Subject: Submission of claim with proof in the matter of [name of guarantor]. Madam/Sir, [Name of the creditor], hereby submits the claim with proof in respect of the resolution process of [name of guarantor]. The details for the same are set out below: 1. Title and full name of creditor 2. Identification number of creditor Aadhaar Number PAN CIN GSTIN 3. Address Present Permanent Business 4. Email 5. Total amount of claim (Including any interest as on the resolution process commencement date) 6. Details of documents by reference to which the debt is substantiated 7. Details of any dispute, as well as the record of such dispute with respect to claim (if any) 8. Details of how debt was incurred and the date when such debt was incurred 9. Details of any mutual credit, mutual debts, or other mutual dealings between the guarantor and the creditor, which may be set-off against the claim 10. Details of any retention of title arrangements in respect of goods or properties to which the claim refers

11. Details of the bank account to which the amount of the claim or any part thereof can be transferred pursuant to a repayment plan (Account Number, IFS Code, Branch and Bank) 12. Details of any security held (including value and date when it was given) 13. If you are a secured creditor, tick the applicable box in the right column relating to forfeiture of right to enforce security during the period of the repayment plan, which will determine the voting share as per section 110 of the Code □ I agree to forfeit my right to enforce my security [insert description] during the period of the repayment plan. □ I do not agree to forfeit my right to enforce my security [insert description] during the period of the repayment plan. 14. (i) Amount claimed by me in the corporate insolvency resolution process / liquidation process of the corporate debtor (ii) The amount admitted by the resolution professional / liquidator of said process (iii) Amount realised by me in the said process, if any 15. Following information regarding the guarantor (to the extent known)- Assets of the guarantor Business of the guarantor Firms in which guarantor is a partner Bank account details of the guarantor Name, age and address of spouse, children, parents and siblings of the guarantor Signature of creditor or person authorised to act on his behalf [Please enclose the authorisation document if this form is being submitted on behalf of a creditor] Name in block letters Address of person signing DECLARATION I, [name of creditor], currently residing at [insert address], hereby declare and state as follows:- 1. [Name of guarantor], the guarantor was, at the resolution process commencement date, being the [date] of [year], indebted to me to the sum of Rs. [insert amount of claim]. 2. In respect of my claim of the said sum or any part thereof, I have relied on the following documents: (a) (b) (c) (d) . . . 3. The aforesaid 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 guarantor and the creditor which may be set-off against the claim.] Date: Place: (Signature of the creditor) VERIFICATION I, [Name of creditor] the creditor hereinabove, do hereby verify that the contents of this proof of claim are true and correct to the best of my knowledge and belief and that no material facts have been concealed therefrom.

Verified at ______ on this _____ day of ____ 20__ (Signature of the creditor)