Form I

Withdrawal from Corporate Voluntary Liquidation Account [Under Regulation 39(7) of the Insolvency and Bankruptcy Board of India (Voluntary Liquidation Process) Regulations, 2017] Sl. No. Description Particulars (1) (2) (3) 1 Name of the Corporate Person 2 Identification Number of Corporate Person (CIN/LLPIN) 3 Voluntary Liquidation Commencement Date 4 Date of Dissolution Order 5 Date of Deposit into the Corporate Voluntary Liquidation Account 6 Name of the Stakeholder seeking withdrawal 7 Identification Number of the Stakeholder a. PAN b. CIN/LLPIN/DIN c. Aadhaar No. 8 Address and Email Address of Stakeholder 9 Amount of Claim of the Stakeholder, admitted by the Liquidator 10 Amount of unclaimed dividends / undistributed proceeds deposited by the Liquidator in the Corporate Voluntary Liquidation Account against the stakeholder 42 Substituted by Notification No. IBBI/2022-23/GN/REG.081., dated 5th April, 2022 (w.e.f. 05-04- 2022). Before substitution, it stood as: ““Form-H”.

11 Amount of unclaimed dividends / undistributed proceeds the Stakeholder seeks to withdraw from the Corporate Voluntary Liquidation Account 12 Bank Account to which the amount is to be transferred from the Corporate Voluntary Liquidation Account, if withdrawal is approved (a) Account No.: (b) Name of Bank: (c) IFSC: (d) MICR: (e) Address of Branch of the Bank: 13 Reasons for not taking dividend or proceeds during the Voluntary Liquidation Process 14 Any legal disability in applying for withdrawal? (Yes / No), If yes, please provide details DECLARATION I, [Name of stakeholder], currently residing at [insert address], hereby declare and state as follows: 1. I am entitled to receive a sum of Rs…. (Rupees … only) from the Corporate Voluntary Liquidation Account, as presented above. 2. In respect of the said sum or any part thereof, neither I nor any person, by my order, to my knowledge or belief, for my use, has received any manner of satisfaction or security whatsoever, save and except the following: ............... 3. I undertake to refund the entire amount with interest as decided by the Board, in case the Board finds that I am not entitled to this amount. 4. I authorise the Board to initiate appropriate legal action against me if my claim is found false at any time. Date: Place: (Signature of the Stakeholder) VERIFICATION I, [Name] the stakeholder hereinabove, do hereby verify that the contents of this Form are true and correct to my knowledge and belief and no material fact has been concealed therefrom. Verified at … on this …… day of ………., 20… (Signature of the Stakeholder) [Note: In the case of a company or limited liability partnership, the declaration and verification shall be made by the director/manager/secretary/ designated partner and in the case of other entities, an officer authorised for the purpose by the entity]]