Form C

[See rule 7(2)] APPLICATION BY CREDITOR TO INITIATE INSOLVENCY RESOLUTION PROCESS

[Under rule 7(2) of the Insolvency and Bankruptcy (Application to Adjudicating Authority for

Insolvency Resolution Process for Personal Guarantors to Corporate Debtors) Rules, 2019] [Date]

To The Adjudicating Authority [Address]

From [Name and address of the creditor]

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

guarantor] under the Code. Madam/Sir,

[Name of the creditor], hereby submits this application to initiate an insolvency resolution process in

the case of [name of guarantor].

The details for the purpose of this application are set out below: Part - I

PARTICULARS OF APPLICANT 1. Title and full name

2. Date of birth and e-mail address

3. Contact number(s) Home Mobile Business

4. Identification number Aadhaar

number CIN PAN GSTIN

¹Hkkx IIμ[k.M 3(i)] Hkkjr dk jkti=k % vlk/kj.k 27 5. Address Present Permanent Business

6. Bank Account details (Joint and Several) Account

number IFSC Code Name of the Bank

and Branch

Address Part – II

PARTICULARS OF THE GUARANTOR 1. Title and full name

2. Date of birth and e-mail address (to the extent

known) 3. Any other name by which the guarantor is or has

been known (as applicable) (to the extent known) 4. Address Present Permanent Business

5. Occupation/ Business/ Profession

6. Annual income (to the extent known) 7. List of associates of the guarantor, including

relatives, who may be creditors (to the extent

known) Name Age Address

8. Bank account details (Joint and Several) Account

number IFSC Code Name of the bank

and Branch

address 9. Identification number Aadhaar

number Passport number PAN GSTIN

10. Contact number(s) Home Mobile Business

11. List of assets of guarantor as on the application

date (to the extent known) Note: this will include all assets of guarantor,

irrespective of them being 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 12. Number of directorships held in the preceding three

years (along with name of company in which

directorship is held) and CIN of such companies 13. Marital status (single, married, divorced, widowed,

co-habiting, separated, or specify any other) (to the extent known) 14. Details regarding personal guarantor (in addition to information in serial numbers 1-13 of this part) -

Name of corporate debtor for which guarantee is given Any current or past position held in the corporate debtor (to the extent known) Identification number of the corporate debtor Whether corporate debtor is an associate (to the extent known) Any securities held in corporate debtor for whom guarantee is given 15. Where the guarantor is not resident in India, the

name and address of person resident in India

authorised to accept the service of process on

guarantor’s behalf

¹Hkkx IIμ[k.M 3(i)] Hkkjr dk jkti=k % vlk/kj.k 29 Part-III

PARTICULARS OF DEBT 1. Total debt (including any interest or penalties)

2. Amount in default

3. Date on which debt was due

4. Date on which default occurred

5. Nature of the debt

6. Secured debt including particulars of security

held, the date of its creation, its estimated value as per the creditor (as applicable) 7. Unsecured debt (as applicable)

8. Details of retention of title arrangements (if

any) in respect of goods to which the debt refers (attach a copy) 9. Details of any mutual credit, mutual debts, or

other mutual dealings between the guarantor and the creditor, which may be set-off against the claim (attach proof) 10. Particulars of an order of a court, tribunal or

arbitral panel adjudicating on the default, if any (attach a copy of the order) 11. Record of default with the information utility,

if any (attach a copy) 12. Details of succession certificate, or probate of

a will, or letter of administration, or court decree (as may be applicable), under the Indian Succession Act, 1925 (10 of 1925) (attach a copy) 13. Provision of law, contract or other document

under which debt has become due (attach a copy) 14. A statement of bank account where deposits

are made or credits received normally by the creditor in respect of the debt of the corporate debtor, from the date on which the debt was incurred (attach a copy) 15. List of documents attached to this application

in order to prove the existence of debt and the amount in default 16. Statement by creditor in respect of excluded

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

which the insolvency resolution process application is filed 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. 17. If you are a secured creditor, tick the applicable

box in the right column relating to forfeiture of right to enforce security during the period of the repayment plan, which will determine the voting share as per section 110 of the Code □ I agree to forfeit my right to enforce my

security [insert description] during the

period of the repayment plan. □ I do not agree to forfeit my right to enforce

my security [insert description] during the

period of the repayment plan. Part-IV [Name of the creditor] has paid the requisite fee for this application through [state means of payment] on

[date].

Yours sincerely, Signature of creditor/ person authorised to act on behalf of the creditor [Please enclose the authorisation document if this application is being submitted on behalf of the creditor]

Name in block letters Address of person signing PARTICULARS OF & DECLARATION BY INSOLVENCY PROFESSIONAL (IF APPLICATION

FILED THROUGH INSOLVENCY PROFESSIONAL) 1. Title and full name

2. Address Present Permanent Business

3. E-mail address(es)

4. Contact number Home Mobile Business

5. Declaration by

insolvency professional I, [name of insolvency professional], an insolvency professional enrolled with

[name of insolvency professional agency] having registration number

[registration number.] have been proposed as the resolution professional by

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

resolution process of [name of the guarantor].

I hereby: (i) agree to accept appointment as the resolution 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 interim resolution professional / resolution professional / authorized representative / 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];

(v) affirm that I am eligible to be appointed as a resolution professional in respect of the guarantor in accordance with the Insolvency and Bankruptcy Board of India (Insolvency Resolution 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)

¹Hkkx IIμ[k.M 3(i)] Hkkjr dk jkti=k % vlk/kj.k 31 List of documents to be attached to the application: 1. All documents mentioned in serial number. 15 of Part III of this form.

2. Copy of the demand notice served on the guarantor in Form B.

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, if available. 4. Copy of the personal guarantee contract.

5. Copy of the authorisation, wherever required under this form.

6. Proof that the application fee has been paid.

7. Documents evidencing the debt and the default in relation to the debt, as may have been provided by

the guarantor at any point in time, if available. 8. Documents evidencing the assets, liabilities, income and any other relevant information as may have

been provided by the guarantor at any point in time, if available. 9. Documentary evidence of all information sought in each entry for each Part of the form.