Form C

PROOF OF CLAIM BY FINANCIAL CREDITORS (Under Regulation 17 of the Insolvency and Bankruptcy Board of India (Voluntary Liquidation Process) Regulations, 2017) [Date] To The Liquidator [Name of the Liquidator] [Address as set out in the public announcement] From [Name and address of the registered office and principal office of the financial creditor]

Subject: Submission of proof of claim in respect of the voluntary liquidation of [name of corporate person] under the Insolvency and Bankruptcy Code, 2016. Madam/Sir, [Name of the financial creditor] hereby submits this proof of claim in respect of the voluntary liquidation of [name of corporate person]. The details for the same are set out below: 1. NAME OF FINANCIAL CREDITOR (IF AN INCORPORATED BODY PROVIDE IDENTIFICATION NUMBER AND PROOF OF INCORPORATION, IF A PARTNERSHIP OR INDIVIDUAL PROVIDE IDENTIFICATION RECORDS* OF ALL THE PARTNERS OR THE INDIVIDUAL) 2. ADDRESS AND EMAIL OF FINANCIAL CREDITOR FOR CORRESPONDENCE. 3. TOTAL AMOUNT OF CLAIM, INCLUDING ANY INTEREST, AS AT THE LIQUIDATION COMMENCEMENT DATE AND DETAILS OF NATURE OF CLAIM (WHETHER TERM LOAN, SECURED, UNSECURED) 4. DETAILS OF ANY ORDER OF A COURT OF TRIBUNAL THAT HAS ADJUDICATED ON THE NON-PAYMENT OF DEBT 5. DETAILS OF HOW AND WHEN DEBT INCURRED 6. DETAILS OF ANY MUTUAL CREDIT, MUTUAL DEBTS, OR OTHER MUTUAL DEALINGS BETWEEN THE CORPORATE PERSON AND THE FINANCIAL CREDITOR WHICH MAY BE SET-OFF AGAINST THE CLAIM 7. DETAILS OF ANY SECURITY HELD, THE VALUE OF THE SECURITY, AND THE DATE IT WAS GIVEN 8. DETAILS OF ANY ASSIGNMENT OR TRANSFER OF DEBT IN HIS FAVOUR 9. DETAILS OF THE BANK ACCOUNT TO WHICH THE FINANCIAL CREDITOR’S SHARE OF THE PROCEEDS OF LIQUIDATION CAN BE TRANSFERRED 10. LIST OUT AND ATTACH THE DOCUMENTS(i) BY REFERENCE TO WHICH THE DEBT CAN(ii) BE SUBSTANTIATED AND IN SUPPORT OF THE CLAIM. Signature of financial creditor or person authorised to act on his behalf (please enclose the authority if this is being submitted on behalf a financial creditor)

Name in BLOCK LETTERS Position with or in relation to creditor Address of person signing *PAN, Passport, AADHAAR Card or the identity card issued by the Election Commission of India. AFFIDAVIT I, [name of deponent], currently residing at [address of deponent], do solemnly affirm and state as follows: 1. The above named corporate person was, at the voluntary liquidation commencement date, that is, the __________ day of __________ 20____ and still is, justly and truly indebted to me [or to me and[insert name of co-partners], my co-- partners in trade, or, as the case may be] for a sum of Rs. __________ for ……..[please state consideration]. 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 debt and of non-payment.] 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 have my partners or any of them, nor has any person, by my/our order, to my/our knowledge or belief, for my/ our 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 corporate person and the financial creditor which may be set-off against the claim.] Solemnly, affirmed at _____________________ on _________________ day, the __________day of__________ 20_____ Before me, Notary / Oath Commissioner. Deponent's signature. VERIFICATION

I, the Deponent hereinabove, do hereby verify and affirm that the contents of para ___ to __of this affidavit are true and correct to my knowledge and belief. Nothing is false and nothing material has been concealed therefrom. Verified at ________ on this ________ day of ________ 201___. Deponent's signature.