Form D

PROOF OF CLAIM BY A WORKMAN OR EMPLOYEE (Under Regulation 18(1) 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 public announcement] From [Name and address of the workman / employee] Subject: Submission of proof of claim in respect of voluntary liquidation of (Name of corporate person) under the Insolvency and Bankruptcy Code, 2016. Madam/Sir, [Name of the workman / employee], 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 WORKMAN / EMPLOYEE 2. PAN, PASSPORT, THE IDENTITY CARD ISSUED BY THE ELECTION COMMISSION OF INDIA OR AADHAAR CARD OF WORKMAN / EMPLOYEE 3. ADDRESS AND EMAIL ADDRESS (IF ANY) OF WORKMAN / EMPLOYEE FOR CORRESPONDENCE 4. TOTAL AMOUNT OF CLAIM (INCLUDING ANY INTEREST AS AT THE VOLUNTARY LIQUIDATION COMMENCEMENT DATE) 5. DETAILS OF ANY DISPUTE AS WELL AS THE RECORD OF PENDENCY OR ORDER OF SUIT OR ARBITRATION PROCEEDINGS 6. DETAILS OF HOW AND WHEN CLAIM AROSE 7. DETAILS OF ANY MUTUAL CREDIT, MUTUAL DEBTS, OR OTHER MUTUAL DEALINGS BETWEEN THE CORPORATE

PERSON AND THE WORKMAN / EMPLOYEE WHICH MAY BE SET-OFF AGAINST THE CLAIM 8. DETAILS OF THE BANK ACCOUNT TO WHICH THE WORKMAN / EMPLOYEE’S SHARE OF THE PROCEEDS OF LIQUIDATION CAN BE TRANSFERRED 9. LIST OUT AND ATTACH THE DOCUMENTS(i) BY REFERENCE TO WHICH THE DEBT CAN(ii) BE SUBSTANTIATED AND RELIED ON IN SUPPORT OF THE(iii) CLAIM. Signature of workman / employee or person authorised to act on his behalf [Please enclose the authority if this is being submitted on behalf of an operational creditor] Name in BLOCK LETTERS Position with or in relation to creditor Address of person signing AFFIDAVIT I, [name of deponent], currently residing at [insert address], do solemnly affirm and state as follows: 1. [Name of corporate person], the corporate person was, at the liquidation commencement date, that is, the __________ day of __________ 20__, justly and truly indebted to me for a 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 documents specified below: [Please list the documents relied on as evidence of claim] The said documents are true, valid and genuine to the best of my knowledge, information and belief. 3. 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 corporate person and the workman / employee which may be set-off against the claim.] Solemnly, affirmed at [insert place] 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 paragraph ___ to __of this affidavit are true and correct to my knowledge and belief and no material facts have been concealed therefrom. Verified at ______ on this _____ day of ____ 201__ Deponent's signature.