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Form Ca Submission of Claim by Financial Creditors in A Class

Suresh Sawant submits a claim as a financial creditor for Rs. 16526 against Pancard Clubs Limited in insolvency resolution, providing details of the debt such as it being incurred in 2011 from membership purchase and attaching a receipt from the PAN office as proof of the claim and non-payment. Sawant declares and verifies the claim and details provided to be true to his knowledge.

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Suraj Sawant
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297 views

Form Ca Submission of Claim by Financial Creditors in A Class

Suresh Sawant submits a claim as a financial creditor for Rs. 16526 against Pancard Clubs Limited in insolvency resolution, providing details of the debt such as it being incurred in 2011 from membership purchase and attaching a receipt from the PAN office as proof of the claim and non-payment. Sawant declares and verifies the claim and details provided to be true to his knowledge.

Uploaded by

Suraj Sawant
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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FORM CA

SUBMISSION OF CLAIM BY FINANCIAL CREDITORS IN A CLASS


(Under Regulation 8A of the Insolvency and Bankruptcy (Insolvency Resolution Process for Corporate Persons)
Regulations, 2016)

From Date
suresh sawant 20/9/2022

963 Majgaon, Khalchiali, Tal. Sawantwadi, Dist. Sindhudurg 416510.

To
The Interim Resolution Professional / Resolution Professional

Rajesh Sureshchandra Sheth

Registered Address: B-55, Shatdal Society, 7th Floor, Azad Lane, Off S.V. Road, Andheri West, Near Shoppers Stop,
Mumbai 400058, Maharashtra

Correspondence Address: Deloitte India Insolvency Professionals LLP, 27th Floor, Tower 3, One International
Center, Senapati Bapat Marg, Elphinstone (W), Mumbai 400 013

Subject: Submission of claim and proof of claim.

Madam/Sir,

suresh sawant, hereby submits this claim in respect of the corporate insolvency resolution process of Pancard
Clubs Limited. The details for the same are set out below:
RELEVANT PARTICULARS

1. Name of the financial creditor suresh sawant

2. Identification number of the financial creditor (If an KAEPS7808Q


incorporated body, provide identification number and proof of
incorporation. If a partnership or individual, provide
identification records of all the partners or the individual)

3. Address and e-mail address of the financial creditor for 963 Majgaon, Khalchiali, Tal. Sawantwadi,
correspondence. Dist. Sindhudurg 416510.,
[email protected]

4. Total amount of claim (in Rs.) 16526

5. Details of documents by reference to which the debt can be receipt by pan office
substantiated.

6. Details of how and when debt incurred. on buying membership on april 2011

7. Details of any mutual credit, mutual debts, or other mutual N.A.


dealings between the corporate debtor and the creditor which
may be set-off against the claim.

8. Details of any security held, the value of the security, and the not applicable
date it was given

9. Details of the bank account to which the amount of the claim Account no: 141010100012098
Ifsc code:
or any part thereof can be transferred pursuant to a resolution BKID0001410
Branch: POKALE
plan BUILDINGUBHA BAZAR, SAWANTWADI
416510

10. List of documents attached to this claim in order to prove the receipt by pan office sawantwadi branch
existence and non-payment of claim due

11. Name of the insolvency professional who will act as the Mr. Vithal Madhukar Dahake
Authorised representative of creditors of the class
Signature of financial creditor or person authorised to act on its behalf

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

Name in BLOCK LETTERS : Suresh sawant

Position with or in relation to creditor :self

Address of person signing :963 Majgaon, Khalchiali, Tal. Sawantwadi, Dist. Sindhudurg 416510.

*PAN number, passport, AADHAAR Card or the identity card issued by the Election Commission of India.
DECLARATION
I, suresh sawant, currently residing at  963 Majgaon, Khalchiali, Tal. Sawantwadi, Dist. Sindhudurg 416510., do
hereby declare and state as follows: -

1. Pancard Clubs Limited, the corporate debtor was, at the insolvency commencement date, being the 9th day
of September 2022, actually indebted to me for a sum of Rs.16526

2. In respect of my claim of the said sum or any part thereof, I have relied on the documents specified below:

receipt by pan office.

3. 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.

4. 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, had or received any manner of satisfaction or security whatsoever, save and except the
following:

N.A.

5. I am not a related party of the corporate debtor, as defined under section 5 (24) of the Code.

6. I am eligible to give voting instruction to the authorized representative by virtue of proviso to section 21 (2)
of the Code even though I am a related party of the corporate debtor.

Date :

Place : (Signature of the claimant)

VERIFICATION

I, suresh sawant the claimant hereinabove, do hereby verify that the contents of this proof of claim 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 claimant)

[Note: In the case of 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 authorized for the
purpose by the entity.]

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