FORM D

PROOF OF CLAIM BY A WORKMAN OR AN EMPLOYEE

[Under Regulation 9 of the Insolvency and Bankruptcy (Insolvency Resolution
Process for Corporate Persons) Regulations, 2016]
Date: 01st March 2018

To
The Interim Resolution Professional / Resolution Professional
Mr.S.RAJENDRAN,
2nd floor, Evalappan Mansion, 188/87, Habibullah Road,
(Near Kodambakkam Railway Station)
T.Nagar,
Chennai-600017.

From
P N SAIRAM
9/4, Buddha Chetty street,
Old Washermenpet,
Chennai - 600021.

Madam/Sir,
I P N SAIRAM hereby submits this proof of claim in respect of the corporate insolvency
resolution process in the case of M/s Nagarjuna Oil Corporation Limited Cuddalore.The details
for the same are set out below:

Particulars:

1. Name of workman / employee: P N SAIRAM

2. Pan number, passport, the identity card issued by the election commission of India or
aadhaar card of workman / employee:
PAN: DMVPS6788H,
The identity card issued by the election commission of India : AYR0881557
Aadhaarcard no: 318950022824.
3. Address and email address (if any) of workman/employee for correspondence:
Permanent address:
P N SAIRAM
9/4, Buddha Chetty street,
Old Washermenpet,
Chennai - 600021.
Tamilnadu.
Mobile: 9597842428,
Mail:saiict046@gmail.com.

Present Address:
P N SAIRAM
9/4, Buddha Chetty street,
Old Washermenpet,
Chennai – 600021,
Tamilnadu.
Mobile: 9597842428.

4. Total amount of claim (including any interest as at the insolvency commencement date) :

Rs 92,205.00. (Ninety two thousand two hundred and five rupees only)

5. Details of documents by reference to which the claim can be substantiated:

a) Pay slips issued by NOCL – 2 months (February to March 2014).

b) Service Certificate issued on 20th April-2015.

c) Increment Letter issued by NOCL on 17th March t -2016.

6. Details of any dispute as well as the record of pendency or order of suit or arbitration
proceedings: NIL
7. Details of how and when claim arose:
I worked for NOCL as an employee from 01st nov-2012 to 08th mar-2016.I had to resign and look
for alternate job as NOCL did not pay my Salary from 1st Marchl-2015 to 09th March-2016
(Inclusive of all eligible allowances) and due share of PF account also quoting financial crisis.
Hence the claim.
8. Details of any mutual credit, mutual debts, or other mutual dealings between the corporate
debtor and the creditor which may be set-off against the claim: NIL

9. Details of the bank account to which the amount of the claim or any part thereof can be
transferred pursuant to a resolution plan:

Name: P N SAIRAM
A/c No: 0777104000036971
IFSC code: IBKL0000777
IDBI Bank, Anna nagar Branch,Chennai.

10. List of documents attached to this proof of claim in order to prove the existence and non-
payment of claim due to the operational creditor

a) Pay slips issued by NOCL – 2 months (February to March 2014).

b) Service Certificate issued on 20th April-2015.

c) Increment Letter issued by NOCL on 17th March t -2016

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

Name in block letters: P N SAIRAM

Position with or in relation to creditor: Junior Engineer
Address of person signing:
P N SAIRAM
9/4, Buddha Chetty street,
Old Washermenpet,
Chennai - 600021.
Mobile: 9597842428,8300540504
Saiict046@gmail.com
AFFIDAVIT
I, P N SAIRAM, currently residing at No.9/4, Buddha chetty street, Old washermenpet ,
Chennai-600021, Tamilnadu do solemnly affirm and state as follows:

1. Nagarjuna Oil Corporation Limited, the corporate debtor was, at the insolvency commencement date,
being the 25th day of July 2017, justly and truly indebted to me in the sum of Rs. 92,205.00
(Ninety two thousand two hundred and five rupees only)

2. In respect of my claim of the said sum or any part thereof, I have relied on the documents specified
below:
a) Pay slips issued by NOCL – 2 months (February to March 2014).

b) Service Certificate issued on 20th April-2015.

c) Increment Letter issued by NOCL on 17th March t -2016

3. The said documents are true, valid and genuine to the best of my knowledge, information and belief.
4. 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: NIL.

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 01th day of March 2018.

Deponent’s signature