FORMCA, ‘SUBMISSION OF C_AIM BY FINANCIAL CRELITORS IN ACLASS (Under Regulation 8A of the Insolvency and Bankruptcy (Insolvency Resolution Process for Corporate Persons) Regulations, 2016) From Date Sushrut Ganpat Deshmukh 2an2te022 E/36IB-3, Shram Safalya Apt, Set-8, NerullW), Navi Mummbai-400706 To ‘The Interim Resolution Professional / Resolution Professional Rajesh Sureshchancra Sheth Ragistered Acdress: 8-55, Shatdal Society, 7th Floor, Azad Lane, Off SV. Road, Andheri West, Near Shoppers Stop, Mumba’ 400058, Maharashtra CCorrespordence Address: Deloitte India Insolvency Professionals LLP, 27th Floor, Tower 3, One International Center, Senapati Sapat Marg, Elphinstone (W), Mumbai 400 013 Subject: Submission of claim and proof of claim, MacamSir, Sushrut Ganpat Deshmukh, 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 PARTIOULARS. 1. Name of the financial creditor Sushrut Ganpat Deshmukh 2. Identification number of the financial cresitor(ifan ass6si882i08 incorporated body, provide identfcation number and proof of Incorporation, tf partnership or ind vidual, provide Identiftation records ofall the partners or the individual 3. Address and e-mailadaress of the Financial creditor for E1/36/8-3, Shram Safalya Apt, Set-8, correspondence, Nerullw), Navi Mumbai-400706, harshsharmasis@outlookcom 4, Totalamount of claim (in Rs) 14400 5, Details of dacuments by reference to which the debt canbe pancard clue policy substantiated, 6 Details of how and when debt incurred, Not applicable/ not availed of any facilities from PanCare Club 7. Details of any mutual credit, mutual debts, or other mutual NA dealings betwoon 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 tne NA date itwas given 9 Details of the bank account to which the amount ef the claim _ State Bank Of India Branch PalmBeach ‘or any part thereof can be transferred pursuant tea resolution Road Nerul saving A/C ne-40547080963 plan IFSC Codes! NOOOSoBE 10. List of cacuments attached to this claim in order to prove the Membership Certificate, Bank Passbook, existence and non-payment of claim due Pancard, Policy submission acknowledgement 11 Name of the insolvency professional who will act as the Mr. vithal Machular Dahake ‘Authorised representative of creditors of the classSignature of financial creditor or person authorised to act on its behalt [Please enclose the authority if this is being submitted on behalf of the financial creditor] Name in BLOCK LETTERS: Sushrux Ganpat Deshmukh Position with or in relation to creditor SELF ‘Adress of person signing :E1/86/3-8, Shram Safalya Apt, Set-8, NerullW, Navi Mumbai-400706 “PAN number, passport, ADHAAR Card or the identity card issued by the Election Commission of India DECLARATION |, Sushrut Ganpat Deshmukh, currently residing at EY/S6/8-3, Shram Safalya Apt, Set-8, Nerul(W), Navi Mumbal-400706, de hereby declare and state as follows: - 1 Pancard Clubs Limited, the corporate debtor was, atthe insolvency commencement date, being the 9th day ‘of September 2022, actually indebted to me for a sum of R14400 2.In respect of my claim of the said sum or any part thereof, have relied on the documents specified below: paneatd club peliey. ‘5. The said documents are true, valid and genuine to the best of my knowledge, information and belief and ne ‘material facts have been concealed therefrom, 4m respect of the said sum of any part thereof, neither I,ner any person, by my order, wo my knowledge or belie, for my use, had or received any manner of satisfaction or security whatsoever, save and except the following: NA 5.lam not a related party ef the corporate debtor, as defined under section 5 (24) of the Code. 6.1 am eligible to give voting instruction to the authorized representative by virtue of proviso to section 21 (2) ‘of the Code even though | am a related party of the corporate debtor. Date: Place (Signature of the claimant) VERIFICATION |, Sushrut Ganpat Deshmukh the claimant hereinabove, do hereby verify that the contents of this proof of claim fact has been concesled therefrom, are true and correct to my knowledge and beliof and no rater Ver 2b ee OP EH ee AY OF nny 20. (Signature of claimant) [Noten the case of company or limited lability partnership, the declaration and verification shall be made by the directovmanagerisecrotary/tesignated partner and in the case of other entities, an officer authorized fer the purpose by the entity]