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 SAVITA BHUSHAN BHADRE mon [BUILDING NO. 12, ROOMNO, 421, LOKSEVA CHS, NEAR SAHKAR CINEMA, CHEMBUR, MUMBAI 400069 0 ‘The Interim Resolution Professional / Resolution Professional Rajesh Sureshchandra Sheth Registered Address: 8.55, Shatdal Society, 7th Floor, Azad Lane, Off SV. Road, Andheri West, Near Shoppers ‘Stop, Mumbai 400058, Maharashtra Correspondence Address: Deloitte india Insolvency Professionals LLP, 27th Floor, Tower 3, One International Center, Senapat Bapat Marg, Elphinstone (W), Mumbai 400.013 Subject: Submission of claion and proof of claim, Madamisir, SAVITA BHUSHAN BHADRE, 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 SAVITA BHUSHAN BHADRE 2. Identification number of the financial creditor (ifan 348707801991 incorporated body, provide identification number end proof of incorporation. if partnership ar individual, provide ‘identification records of all the partners or the individual) 3. Address and e-mail address of the financisl creditor for BUILDING NO. 12, RCOMNO. 421, LOKSEVA. correspondence. CHS, NEAR SAHKAR CINEMA, CHEMBUR, MUMBAI 400089, sairamcreations2012@gmellcom 4 Total amourit of claim (in Rs) voc800 5. Details of documents by reference to which thedebt can be MEMBERSHIP CERTIFICATE substantiated. & Details of how and when debt incurred, PURCHASED MEMBERSHIP OF PANCARD CLUBS ON 293ULY 2012 7, Details of any mutual credit, mutual debts,or other mutual NO oolings between the corporate debtor and the creditor which may be cot-off against the claim. 8. Details of any security held, the value of the security, andthe NO. date twas given 9 Details ofthe bank account to which the amount of the claim AXIS BANK A/C NO: 9210103602243) IFSC oF any part thereof can be transferred pursuant toa resolution UTI0000004 plan 10. Uist of documents attached to this ciaim in order to prove the MEMBERSHIP CERTIFICATE AADHAR ‘existence and non-payment of claim due CARDName of the inealvency professional who will act a5 the Ne Devang Subedh Thakar ‘Authorised representative of creditors ofthe class signature of financial creditor or person authorised to act on its behalt [Please enclose the authority it this is being submitted on behalf of the financial creditor] Name in BLOCK LETTERS :SAVITA BHUSHAN BHADRE Position with er in relation to crecitor SELF ‘Address of person signing BUILDING NO. 12, ROOMNO. 47), LOKSEVA CHS, NEAR SAHKAR CINEMA, CHEMBUR, MUMBA! 400089) PAN number passport, ADHAAR Card or the identity car issued by the Election Commission of India. DECLARATION, |, SAVITA BHUSHAN BHADRE, currently residing at BUILDING NO. 12, ROOMNO, 421, LOKSEVA CHS, NEAR SAHKAR CINEMA, CHEMBUR, MUMBAI 400089, 40 hereby deciare 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 fora sum of Rs.100800 2 Inrespect of my claim of the said sum or any part thereof, | have relied on the documents specified below: MEMBERSHIP CERTIFICATE, ‘3. The sid documents are true, valid and genuine tothe best of my knowledge, information and belief and no material facts have been concealed therefrom, : cin respect ofthe said sum cr aryy part thereof, neither I, ner any person, by my order, to my knowledge O° belies for my use, had or received any manner of satisfaction or security whatsoever, save and except the following: NO 51am nota related party of the corporate debtor. as defined under section 5 (24) of the Code. 6.1 ameligible to give voting instruction to the authorized representative by virtue of provso to section 21 (2) ‘ofthe Code even though | am a related party of the corporate debtor. pote: Thi) rea ; der place: Muha) |signatde of the claimant) VERIFICATION |/SAVITA BHUSHAN BHADRE 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. Verited ot Tfhiteaed on this 40. day ot Mevi2022. le (GignatSed of claimant) [Note tn the ease of company or limited liablity partnership, the declaration and verification shall be macie by the directorimanager/secretatyidesignated partner and in the case of ether entities, an officer authorized for the purpose by the entity)