SCHEDULE

FORM D

PROOF OF CLAIM BYA WORKMAN OR AN EMPLOYEE

(Under Regulation 9 of the Insolvency and Bankruptcy (Insolvency Resolution Process for
Corporate Persons) Regulations, 2016)

27th Feb 2023

To
The Interim Resolution Professional / Resolution Professional
Alok Kailash Saksena
1st Floor, Laxmi Building,
Sir P M Road, Fort, Mumbai, Maharashtra ,400001

From
Vinay Rajendraprasad Agrawal

Subject: Submission of proof of claim.

Madam/Sir,

[Name of the workman / employee], hereby submits this proof of claim in respect of the
corporate insolvency resolution process in the case of [name of corporate debtor]. The details
for the same are set out below:

PARTICULARS

1. NAME OF WORKMAN / EMPLOYEE VINAY RAJENDRASPRASAD AGRAWAL

2. PANNUMBER, PASSPORT, THE IDENTITY PAN- BIHPA6220L

CARD ISSUED BY THE ELECTION
COMMISSION OF INDIA ORAADHAAR
CARD OF WORKMAN / EMPLOYEE
3. ADDRESS AND EMAIL ADDRESS (IF ANY) C/O K D PRINTEX, NEAR SUBODH CHOWK,
OF WORKMAN / EMPLOYEE FOR GANESH NAGAR, GONDIA - 441601
CORRESPONDENCE
4. TOTAL AMOUNT OF CLAIM 79,967 /-

(INCLUDING ANY INTEREST AS AT THE (SEVENTY NINE THOUSAND NINE

INSOLVENCY COMMENCEMENT DATE) HUNDRED & SIXTY SEVEN ONLY)

5. DETAILSOF DOCUMENTS BY REFERENCE FULL & FINAL SETTLEMENT

TO WHICH THE CLAIM CAN BE RELIEVING LETTER
SUBSTANTIATED.
PARTICULARS

6. DETAILS OF ANY DISPUTE AS WELL AS NA

THE RECORD OF PENDENCY OR ORDER OF
SUIT OR ARBITRATION PROCEEDINGS

7. DETAILS OF HOW AND WHEN CLAIM RESIGNED ON 31AS AUGUST 2021

AROSE

8. DETAILS OF ANY MUTUAL CREDIT, NA

MUTUAL DEBTS, OR OTHER MUTUAL
DEALINGS BETWEEN THE CORPORATE
DEBTOR AND THE CREDITOR WHICH MAY
BE SET-OFF AGAINST THE CLAIM

9. DETAILS OF THE BANK ACCOUNT TO BANK OF BARODA

WHICH THE AMOUNT OF THE CLAIM OR SADAR NAGPUR BRANCH
ANY PART THEREOF CAN BE A/C NO: 08990100013702
TRANSFERRED PURSUANT TO A IFSC : BARB0SADNAG
RESOLUTION PLAN
10. LIST OF DOCUMENTS ATTACHED TO THIS FULL & FINAL SETTLEMENT
PROOF OF CLAIM IN ORDER TO PROVE RELIEVING LETTER
THE EXISTENCE AND NON-PAYMENT OF
CLAIM DUE TO THE OPERATIONAL
CREDITOR

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

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

Name in BLOCK LETTERS : VINAY RAJENDRAPRASAD AGRAWAL

Position with or in relation to creditor : SENIOR OFFICER

Address of person signing

 DECLARATION
I, Vinay Agrawal, currently residing at Ganesh nagar, Gondia, do hereby declare and state as
follows:-

1. Topworth Urja & Metals Limited, the corporate debtor was, at the insolvency
commencement date, being the 12th day of August 2023, actually indebted to me in
the sum of Rs. 79,967 /-

In respect of my claim of the said sum or any part thereof, I have relied on the documents
specified below:
A. FULL & FINAL SETTLEMENT
B. RELIEVING LETTER

1. 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.

2. 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: NA

Date: 27-02-2023
Place: GONDIA

(Signature of the claimant)

VERIFICATION

I, VINAY AGRAWAL 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 GONDIA on this 27th day of August 2023.

(Signature of claimant).