Form A

[See rule 6(1)] APPLICATION BY GUARANTOR TO INITIATE BANKRUPTCY PROCESS.

[Under rule 6 of the Insolvency and Bankruptcy (Application to Adjudicating Authority for Bankruptcy

Process for Personal Guarantors to Corporate Debtors) Rules, 2019]

[Date]

To, The Adjudicating Authority [Address]

From, [Name and address of the guarantor]

In the matter of [name of the guarantor] Subject: Application to initiate bankruptcy process in respect of [name of the guarantor].

Madam/Sir, I/ We hereby submit this application to initiate a bankruptcy process in respect of [name of guarantor]. The

details for the purpose of this application are set out below-

Part I PARTICULARS OF THE GUARANTOR 1. Title and full name

2. Date of birth and e-mail address

3. Any other name by which the debtor is or

has been known (as applicable) 4. Address

(i) Present (ii) Permanent (iii) Business 5. Occupation/ Business/ Profession

6. Annual income in the preceding year (in

Rupees) 7. List of associates of the guarantor,

including relatives, who may be creditors Name Age Address

8. Bank account details (Joint and Several) Account number IFSC code Name of Branch and

Branch address 9. Identification numbers Aadhaar

number Passport number PAN GSTIN

10. Contact number(s) Home Mobile Business

11. List of assets of guarantor and immediate

family as on the application date. Note: this will include all assets,

irrespective of them being excluded assets. Please mention which assets are the

excluded assets. Immovable Description Estimated

value Excluded asset or not Movable Description Estimated

value Excluded asset or not Vehicles Shares in listed companies Shares in other companies Life insurance policy Jewellery Pension policy Investment in mutual funds Investment in other funds Investment in partnerships and other business concerns Any other movable property

¹Hkkx IIμ[k.M 3(i)] Hkkjr dk jkti=k % vlk/kj.k 57 12. Number of directorships held in the last

three years (along with name of company in which directorship is held and Directors Identification Number) and CIN of such companies 13. Marital status (single, married, divorced,

widowed, co-habiting, separated, or

specify any other) 14. Details regarding guarantee given by guarantor (in addition to information in serial number 1-13 of this part)

Name of corporate debtor for which

guarantee is given Any current or past position held in the

corporate debtor Identification number of the corporate debtor Whether corporate debtor is an associate as per section 79(2) of the Code (state how) Any securities held in corporate debtor for whom guarantee is given 15. Where the guarantor is not a resident in

India, the name and address of the person authorized to accept the service of process on guarantor’s behalf, along with the

authority Part – II [Please complete this Part if you have been self-employed, or a partner in a firm. If not, go to Part III.] BUSINESS PARTICULARS OF GUARANTOR 1. Name of business and form of business

2. Details of registration, if any

3. Description of business

4. Business address

5. Annual income of guarantor

6. If business organization is a firm, details

mentioned below: (i) Date of joining firm

(ii) Capital subscription as per latest balance sheet

(iii) Profit sharing as per latest balance sheet

(iv) Name, address and authority of person

submitting application on behalf of the firm

Part - III 7. Commencement date of business and date of

close of operations (if applicable) 8. Address where books of accounts / accounting

records are kept (including soft copy records) 9. Whether employees to whom debt owed (state

yes or no, and if yes, details to be mentioned in Part III) PARTICULARS OF DEBT [CREDITOR WISE, AS APPLICABLE] 1. Name(s) of creditor(s)

2. Address

Present Permanent Business

3. Total debt (including any interest or penalties)

4. Amount of debt in default

5. Interest or penalties, if any

6. Date when the debt was due

7. Date when the default occurred

8. Nature of the debt

9. Secured debt including particulars of security held, the date of its creation, estimated value of security as per the creditor 10. Unsecured debt 11. Details of retention of title arrangements (if

any) in respect of goods to which the debt refers 12. Record of default with the information utility,

if any 13. List of documents attached to this application

in order to prove the existence of debt and the amount in default 14. Statement by guarantor in respect of excluded

debts I [ guarantor] hereby state that the debt(s) for

which the bankruptcy process application is filed

¹Hkkx IIμ[k.M 3(i)] Hkkjr dk jkti=k % vlk/kj.k 59 Part-IV 5. Declaration by insolvency professional I, [name of insolvency professional], an insolvency

professional registered with [name of insolvency

professional agency] having registration number

[registration number] have been proposed as the

insolvency professional by [name of applicant guarantor] in connection with the proposed

bankruptcy process of [name of the guarantor].

I hereby: (i) agree to accept appointment as the insolvency

professional if an order of appointment is

passed by the Adjudicating Authority; (ii) state that the registration number allotted to me

by the Board is [insert registration number]

and that I am currently qualified to practice as an insolvency professional; (iii) disclose that I am currently serving as an

insolvency professional / resolution

professional / liquidator/ bankruptcy trustee in [insert number and details of the proceedings]; (iv) certify that there are no disciplinary

proceedings pending against me with the Board or [name of the insolvency professional agency

he is a member of];

does not include any- (i) liability to pay fine imposed by a court or

tribunal; (ii) liability to pay damages for negligence,

nuisance or breach of a statutory,

contractual or other legal obligation; (iii) liability to pay maintenance to any person

under any law for the time being in force; (iv) liability in relation to a student loan;

(v) any other debt prescribed under section

79(15)(e) of the Code. PARTICULARS OF & DECLARATION BY INSOLVENCY PROFESSIONAL (IF PROPOSED TO

ACT AS BANKRUPTCY TRUSTEE) 1. Title and full name

2. Address Present Permanent Business

3. E-mail address(es)

4. Contact number Home Mobile Business

(v) affirm that I am eligible to be appointed as an

insolvency professional in respect of the debtor in accordance with Regulation 3 of the

Insolvency and Bankruptcy Board of India

(Bankruptcy Process for Personal Guarantors to Corporate Debtors) Regulations, 2019; (vi) make the following disclosures in accordance

with the code of conduct for insolvency

professionals as set out in the Insolvency and Bankruptcy Board of India (Insolvency

Professionals) Regulations, 2016 [insert

disclosures, if any].

(Signature of the insolvency professional) Yours sincerely, DECLARATION I, [Name of applicant], currently residing at [insert address], hereby declare and state as follows:

1. In respect of my application for bankruptcy, I have relied on the documents specified below: [Please list

the documents relied on].

2. The contents of the said application along with the said documents are true, valid and genuine to the best of my knowledge, information and belief and no material facts have been concealed therefrom. Date: Place: (Signature of the applicant) . VERIFICATION I, [name of applicant], do hereby verify that the contents of this application 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 ______ 20__ ________ Applicant's signature. Signature of guarantor / person authorized to act on behalf of the guarantor [Please enclose the authorisation document if this application is being submitted on behalf of the guarantor ]

Name in block letters Address of person signing

¹Hkkx IIμ[k.M 3(i)] Hkkjr dk jkti=k % vlk/kj.k 61 ATTACHMENTS: List of documents to be appended to the application: 1. All records of the insolvency resolution process in respect of the guarantor, including the following-

(i) Application for the insolvency resolution process;

(ii) Order(s) of the Adjudicating Authority-

(a) accepting / rejecting the application under serial number (i) above under section 100 of

the Code, as the case may be; (b) approving / rejecting the repayment plan under section 114 of the Code, as the case may

be; (c) declaring that the repayment plan has not been fully implemented under section 118 and

entitling the debtor to apply for bankruptcy, as the case may be; (d) any other order that may have been passed by the Adjudicating Authority in relation to

the insolvency resolution process. 2. All documents mentioned in serial number 13 of Part III of this form. 3. Copy of the income tax returns with detailed computation of the income of the guarantor, or the firm,

as the case may be, for the previous three years. 4. Copy of the personal guarantee contract. 5. Copies of entries in a bankers book in accordance with the Bankers Books Evidence Act, 1891 (18

of 1891) 6. The latest and complete copy of the financial contract reflecting all amendments and waivers to

date. 7. Copies of relevant ownership and title documents for all assets. 8. Copy of the authorisation, wherever required under this form. 9. Proof that the application fee has been paid. 10. Documentary evidence of all information sought in each entry for each part of the form. 11. A statement of affairs of the guarantor made up to a date not earlier than two days from the date of

the application including the following information and supporting documents, namely- (i) debtor’s assets (inclusive of excluded assets) and liabilities for the previous three years;

(ii) secured and unsecured debts (inclusive of excluded debts mentioned in serial number 14

of Part III of the form) with names of the creditors, and all requisite details for the previous three years; (iii) particulars of debt owed by guarantor to associates of the guarantor for the previous three

years; (iv) guarantees given in relation to any of the debts of the guarantor, and if any of the

guarantors is an associate of the guarantor; (v) financial statements with all annexures and schedules for the business owned by the

guarantor, or of the firm in which the guarantor is a partner, as the case may be, for the previous three years, if applicable; (vi) wealth tax statements filed by the guarantor, if any, for the previous five years.

(vii) Income statement of the guarantor, for the previous three years.

(viii) Payment of indirect taxes including GST for the previous three years.