Claim Form Before RP — Financial Creditor Draft

FORM C
[Under Regulation 8 of the Insolvency and Bankruptcy Board of India
(Insolvency Resolution Process for Corporate Persons) Regulations, 2016]

SUBMISSION OF CLAIM BY FINANCIAL CREDITOR

Date: [DD-MM-YYYY]

To,
The Interim Resolution Professional / Resolution Professional,
[Name of IRP/RP], Reg. No. [IBBI/IPA-___/IP-___]
In the matter of CIRP of [Name of Corporate Debtor]
[Address of RP for correspondence].

From,
[Name of Financial Creditor], [Address], [Email], [PAN/CIN].

Subject: Submission of proof of claim as a Financial Creditor under
Regulation 8 of the CIRP Regulations, 2016.

Sir/Madam,

  1. NAME OF FINANCIAL CREDITOR        : [___]
  2. IDENTIFICATION NUMBER (CIN/PAN)   : [___]
  3. ADDRESS & EMAIL FOR CORRESPONDENCE: [___]
  4. TOTAL AMOUNT OF CLAIM (in ₹)      :
        Principal outstanding          : ₹[amount]
        Interest up to insolvency
          commencement date [Date]     : ₹[amount]
        TOTAL CLAIM                    : ₹[amount]
  5. DETAILS OF DOCUMENTS EVIDENCING
     DEBT & DUE DATE OF PAYMENT        :
        [Loan/Facility Agreement dated ___; Sanction Letter ___;
         Deed of Hypothecation/Mortgage ___; NeSL record ___;
         statement of account]
  6. DETAILS OF HOW & WHEN DEBT INCURRED: [disbursement dates & amounts]
  7. DETAILS OF ANY MUTUAL CREDIT / SET-OFF: [NA / details]
  8. DETAILS OF SECURITY HELD, DATE OF
     CREATION, VALUE & CHARGE ID       :
        [Charge on ___ ; ROC Charge ID ___ ; estimated value ₹[amount]]
        ( ) Secured   ( ) Unsecured
  9. DETAILS OF RETENTION OF TITLE
     ARRANGEMENT, if any               : [NA]
 10. DETAILS OF BANK ACCOUNT FOR
     RECEIPT OF DUES                   : A/c [___] Bank [___] IFSC [___]
 11. LIST OF DOCUMENTS ATTACHED TO
     PROVE THE CLAIM                   :
        (i) Loan documents (ii) Statement of account/NeSL record
        (iii) Security/charge documents (iv) Board authorisation
        (v) Computation of interest

AFFIDAVIT / DECLARATION

I, [Name], [Designation], duly authorised by [Financial Creditor] vide
Board Resolution/Power of Attorney dated [___], hereby declare that:

  (a) The above particulars are true and correct to my knowledge;
  (b) [Financial Creditor] is a financial creditor of [Corporate Debtor]
      in respect of the financial debt described above;
  (c) The documents attached are true copies of their originals.

                                        ____________________
                                        (Signature of Financial Creditor
                                         / authorised representative)
                                        Name: [___]
                                        Position: [___]
Place: [___]
Date : [DD-MM-YYYY]

VERIFICATION
Verified at [City] on this [Day] of [Month, Year] that the contents are
true and correct and nothing material has been concealed therefrom.

                                        ____________________
                                        Deponent