PARTICULARS OF THE CORPORATE APPLICANT

1.

Name address, email address, identification number and address for communication of the corporate applicant

[ Name ],[ Address ]

2.

Name address, email address, identification number and address of the registered office of corporate debtor

3.

Names and addresses of all directors, promoters, designated partners of the corporate debtor (as applicable)

4.

Date of incorporation of corporate debtor

5.

Nominal share capital and the paid-up share capital of the corporate debtor and/or details of guarantee clause as per memorandum of association (as applicable)

6.

Name, address and authority of person submitting application on behalf of corporate applicant (enclose Authorisation)

7.

Name and address of person resident in India authorised to accept the service of process on its behalf (enclose authorisation)

8.

Documentation to show that the corporate applicant is authorised to initiate the corporate insolvency resolution process

PARTICULARS OF PROPOSED INTERIM RESOLUTION PROFESSIONAL

1.

Name, address, email address and the registration number of the proposed interim resolution professional

PARTICULARS OF FINANCIAL/OPERATIONAL DEBT [CREDITOR WISE, AS APPLICABLE]

1.

Name(s) of financial/operational creditor(s)

2.

Address of correspondence of the financial/operational creditor(s)

3.

Total debt raised and amount in default

4.

Date when the financial/operational debt was incurred

5.

Particulars of security held, if any, the date of its creation, its estimated value as per the creditor. Attach a copy of a certificate of registration of charge issued by the Registrar of Companies (if the corporate debtor is a company)

6.

Details of retention of title arrangements (if any) in respect of goods to which the operational debt refers

7.

Record of default with the information utility, if any

8.

List of documents attached to this application in order to prove the existence of financial/operational debt and the amount in default

Signature of person authorised to act on behalf of the corporate applicant                                                                                                          

Name in block letters

Position with or in relation to the operational creditor

Address of person signing

Annex I

In case of financial debt, record of default obtained through the information utility or all documents listed in serial number 8 of part –III of this application.

Annex II

In case of operational debt, (i) copy of invoice/demand notice served by an operational creditor on the corporate debtor and (ii) record of default obtained through the information utility or all documents listed in serial number 8 of part-III of this application.

Annex III

Written communication by the proposed interim resolution professional as set out in Form 2 of the Insolvency and Bankruptcy (Application to Adjudicating Authority) Rules, 2016.

Annex IV

Copy of the relevant books of accounts of the corporate debtor evidencing the default to creditors.

Annex V

Copies of audited financial statements of the corporate debtor for the last two financial years and the provisional financial statements for the current financial year made upto a date not earlier than fourteen days from the date of the application.

Annex VI

A statement of affairs made up to a date not earlier than fourteen days from the date of application including the following document, namely:—

1. A list of the corporate debtor's assets and liabilities, divided into such categories as are appropriate for easy identification, with estimated values assigned to each category;

2. In the case of any property on which a claim against the corporate debtor is wholly or partly secured, particulars of the claim and its amount, and of how and when the security was created;

3. The names and addresses of the financial creditors and operational creditors of the corporate debtor, with the amounts due to each of them;

4. Particulars of any debts owed by or to the corporate debtor to or by persons connected with it;

5. Whether any, and if so what, guarantees have been given in relation to the debts of the corporate debtor by other persons, specifying which, if any, of the guarantors is a related party to the corporate debtor and the corporate applicant; and

6. The names and addresses of the members and partners of the corporate debtor, as the case may be, with details of their respective shareholdings.

Annex VII

A copy of:

1. Relevant extract of any constitutional document or shareholders' agreement that records the authority of the corporate applicant to make this application, where the corporate applicant is a member or partner of the corporate debtor; or

2. Relevant extract of an employment agreement, constitutional document or fillings made to the Registrar of Companies confirming the authority of the corporate applicant to make this application, where the corporate applicant is an individual in charge of managing the operations and resources of the corporate debtor or has control and supervision over the financial affairs of the corporate debtor.

Annex VIII

Affidavit in support of the application in accordance with the Insolvency and Bankruptcy (Application to Adjudicating Authority) Rules, 2016.

Annex IX

Proof that the specified application fee has been paid.