Schedule Ii Form E Proof of Claim by A Workman or Employee: Sandhya Prakash Limited

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SCHEDULE II

FORM E

PROOF OF CLAIM BY A WORKMAN OR EMPLOYEE


(Under Regulation 19 of the Insolvency and Bankruptcy (Liquidation Process) Regulations, 2016)

[Date]
To,
The Devendra jain,
(Liquidator of Sandhya Prakash Limited),

Mall Management Office, Shop No. 6,


2nd Floor, Aura Mall,
Opposite Rajeev, Gandhi College
Trilanga, Gulmohar, E-8, Arera Colony
Bhopal( M.P )-4620239

From
[Name and address of the workman / employee]

Subject: Submission of proof of claim in respect of liquidation of Sandhya Prakash Limited under the
Insolvency and Bankruptcy Code, 2016.
Madam/Sir,
[Name of the workman / employee], hereby submits this proof of claim in respect of the liquidation of
Sandhya Prakash Limited. The details for the same are set out below:

1. NAME OF WORKMAN/EMPLOYEE

PAN, PASSPORT, THE IDENTITY CARD ISSUED BY THE


2. ELECTION COMMISSION OF INDIA OR AADHAAR
CARD OF WORKMAN / EMPLOYEE

ADDRESS AND EMAIL ADDRESS (IF ANY) OF


3.
WORKMAN / EMPLOYEE FOR CORRESPONDENCE

TOTAL AMOUNT OF CLAIM


4. (INCLUDING ANY INTEREST AS AT THE LIQUIDATION
COMMENCEMENT DATE)

5. DETAILS OF DOCUMENTS BY REFERENCE TO WHICH


THE DEBT CAN BE SUBSTANTIATED.

DETAILS OF ANY DISPUTE AS WELL AS THE RECORD


6. OF PENDENCY OR ORDER OF SUIT OR ARBITRATION
PROCEEDINGS

7. DETAILS OF HOW AND WHEN CLAIM AROSE

8. DETAILS OF ANY MUTUAL CREDIT, MUTUAL DEBTS,


OR OTHER MUTUAL DEALINGS BETWEEN THE
CORPORATE DEBTOR AND THE WORKMAN /
EMPLOYEE WHICH MAY BE SET-OFF AGAINST THE
CLAIM

DETAILS OF THE BANK ACCOUNT TO WHICH THE


9. WORKMAN / EMPLOYEE’S SHARE OF THE PROCEEDS
OF LIQUIDATION CAN BE TRANSFERRED

LIST OUT AND ATTACH THE DOCUMENTS RELIED ON (i)


10. IN SUPPORT OF THE CLAIM. (ii)
(iii)

Signature of workman / employee or person authorised to act on his behalf


[Please enclose the authority if this is being submitted on behalf of an operational creditor]

Name in BLOCK LETTERS

Position with or in relation to creditor

Address of person signing

AFFIDAVIT
I, [name of deponent], currently residing at [insert address], do solemnly affirm and state as follows:

5. [Name of corporate debtor], the corporate debtor was, at the liquidation commencement date, that
is, the day of 20 , justly and truly indebted to me in the sum of Rs.
[insert amount of claim].

6. 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 claim]

7. The said documents are true, valid and genuine to the best of my knowledge, information and belief.

8. In respect of the said sum or any part thereof, I have not nor has any person, by my order, to my
knowledge or belief, for my 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 debtor and the workman / employee which may be set-off against the claim.]

Solemnly, affirmed at [insert place] 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 paragraph to of this
affidavit are true and correct to my knowledge and belief and no material facts have been concealed
therefrom. Verified at on this day of 201 .

Deponent's signature.

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