Form F

PROOF OF CLAIM BY ANY OTHER STAKEHOLDER (Under Regulation 19of 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 other stakeholder] 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 stakeholder] hereby submits this proof of claim in respect of the liquidation in the case of [name of corporate person]. The details for the same are set out below: 1. NAME OF STAKE-HOLDER (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 THE STAKEHOLDER FOR CORRESPONDENCE. 3. TOTAL AMOUNT OF CLAIM, INCLUDING ANY INTEREST AS AT LIQUIDATION COMMENCEMENT AND DETAILS OF NATURE OF CLAIM 4. DETAILS OF HOW AND WHEN CLAIM AROSE 5. DETAILS OF ANY MUTUAL CREDIT, MUTUAL DEBTS, OR OTHER MUTUAL DEALINGS BETWEEN THE CORPORATE PERSON AND THE

OTHER STAKEHOLDER WHICH MAY BE SET-OFF AGAINST THE CLAIM 6. DETAILS OF ANY RETENTION OF TITLE IN RESPECT OF GOODS OR PROPERTIES TO WHICH THE CLAIM REFERS 7. DETAILS OF ANY ASSIGNMENT OR TRANSFER OF DEBT IN HIS FAVOUR 8. DETAILS OF THE BANK ACCOUNT TO WHICH THE OTHER STAKEHOLDER’S SHARE OF THE PROCEEDS OF LIQUIDATION CAN BE TRANSFERRED 9. LIST OUT AND ATTACH THE DOCUMENTS BY REFERENCE TO WHICH THE CLAIM CAN BE SUBSTANTIATED OR WHICH CAN BE RELIED UPON IN SUPPORT OF THE CLAIM. (i) (ii) (iii) Signature of stakeholder or person authorised to act on his behalf (Please enclose the authority if this is being submitted on behalf of the other stakeholder) 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, [insert full name, address and occupation of deponent to be given] 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 me [or to me and [insert name of co-partner], 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 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, 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 other stakeholder 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. 39