Form E

PROOF OF CLAIM BY AUTHORISED REPRESENTATIVE OF WORKMEN OR EMPLOYEES (Under Regulation 18(2) 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 authorised representative of workmen/ employees] 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, I, [name of duly authorised representative of the workmen/ employees] currently residing at [address of duly authorised representative of the workmen/ employees], on behalf of the workmen and employees employed by the above named corporate person, solemnly affirm and say: 1. That the abovenamed corporate person was, on the voluntary liquidation commencement date, that is, the ________ day of ______ 20 ___ and still is, justly truly indebted to the several persons whose names, addresses, and descriptions appear in the Annexure below for amounts severally set against their names in such

Annexure for wages, remuneration and other amounts due to them respectively as workmen or/ and employees in the employ of the corporate person in respect of services rendered by them respectively to the corporate person during such periods as are set out against their respective names in the said Annexure. 2. That for which said sums or any part thereof, they have not, nor has any of them, had or received any manner of satisfaction or security whatsoever, save and except the following: [Please state details of any mutual credits, mutual debts, or other mutual dealings between the corporate person and the workmen / employees which may be set-off against the claim.] Signature: ANNEXURE 1. Particulars of how dues were incurred by the corporate person, including particulars of any dispute as well as the record of pendency of suit or arbitration proceedings. 2. Particulars of any mutual credit, mutual debts, or other mutual dealings between the corporate person and the workmen / employee which may be set-off against the claim. 3. Please list out and attach the documents relied on to prove the claim. 1. Details of Employees/ Workmen

S | NAME OF | IDENTIFICATION TOTAL | PERIOD | DETAILS OF

NO. EMPLOYEE/ NUMBER | AMOUNT DUE OVER | EVIDENCE OF

WORKMEN | (PAN/, | AND DETAILS WHICH | DEBT

PASSPORT | ON NATURE OF AMOUNT | INCLUDING

NUMBER/, | CLAIM | DUE | EMPLOYMENT

AADHAAR NO. / | CONTRACTS ID CARD ISSUED | AND OTHER BY THE | PROOFS ELECTION COMMISSION AND EMPLOYEE NO.,IF ANY 1. 1. 2. 2. 3. 3.

4. AFFIDAVIT I, [insert full name, address and occupation of deponent] do solemnly affirm and state as follows: 1. The above named corporate person was, at the liquidation commencement date that is, the __________ day of __________ 20__ and still is, justly and truly indebted to the workmen and employees for a sum of Rs. __________ for _____ [please state the nature and duration of employment]. 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 proof] 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, the workmen / employees have not, nor has any person, by my order, to my knowledge or belief, for my use, had or has 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 workmen / employees 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