FORM CA, ‘SUBMISSION OF CLAIM BY FINANCIAL CREDITORS IN A.CLASS. . (Under Regulation 8A ofthe Insolvency and Bankruptcy (Insolvency Resolution Process for Corporate Persons) Regulations, 2016) From Date (Lae visHWwas GHOGARE 229022 NEAR TRIMURTI HANUMAN TEMPLE, ROOM NOS, CANGABAI BAKARIWALI CHAW/L, BHATWADI, GHATKOPAR WEST, MUMBAI - 400084 , To = The Interim Resolution Professional / Resolution Professional Rajesh Sureshchandre Sheth Registered Address £-s, Shatdal Society, th Floor, Azad Lane, Off SV. Road, Andherl West, Neat Shoppers Stop, Mumbai 400058, Maharashtra Correspondence Address: Deoitte india Insolvency Profestionels LLP. 27th Floor, Tower 3. One international Center, Senapati Bapat Marg, Elphinstone (W), Mumbai 400 013 Subject Submission of claim and proof of claim. Madamsir, LAXMI VISHWAS GHOGARE, 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 LAXMI VISHWAS GHOGARE 2. Identification number of the Financial creditor fan BEFPC9s660 Incorporated body, provide identification number and proof of incorporation. Ifa partnership or individual, provide identification records of all the partners ar the individual) 3. Address and e-mail address of the financial eecitor for NEAR TRIMURTI HANUMAN TEMPLE, correspondence, ROOM NOS, GANGABAI BAKARIWAL CCHAWL, BHATWADI, GHATKOPAR WEST, MUMBAI - 400084, laxrighogares7@gmallcom 4 Total amount of claim (in Re) 1720 5. Detalls of documents by reference to which the debt can be PAN CARD CLUB CERTIFICATE, PAN CARD. substantiated (CLUB RECEIPT, PAN CARD, AADHAR CARD, BANK PASSBOOK © Details of how and when debt incurred, (ON BUVING MEMBERSHIP ON 12/1/2016 TO 02018 7. Details of ary mutual credit, mutual debts, or ther mutual NA dealings between the corporate debtor and the creditor which : ‘may be set-off against the claim, 5. Details of any security held the value ofthe security. and the NA. ate twas given % Details of te bank account to which the amount af the claim BANK: SARASWAT BANK AIC NO. ‘or any part thereof can be transferred pursuant toa resolution | 123200100026556 IFSC CODE plan SRCB000DT2310. List ef documents attached to this claim in order to prove the PAN CARD CLUB CERTIFICATE, PAN CARD existence and non-payment of claim due CLUB RECEIPT, PAN CARD, AADHAR CARD, BANK PASS00K 1. Name of the insolvency professional who will act as the Mr. Vithat Madhukar Dahake ‘Authorised representative of creditors of the class : Signature of financial creditor or person authorised to 2et on its behalf [Please enclose the sutnorityifthiss being submitted on behalf ofthe financial creditor] ‘Name in BLOCK LETTERS : LAXMI VISHWAS GHOGARE « Position with orin relation to creditor SELF ‘Address of petson signing —- NEAR TRIMURT! HANUMAN TEMPLE, ROOM NOS, GANGABAI BAKARIWAL! CHAWL, BHATWADI, GHATKOPAR WEST, MUMBAI - 400084 *PAN rumber, passport, AADHAAR Card or the Identity card issued by the Election Commission of India DECLARATION |. LAXMI VISHWAS GHOGARE, currently residing at NEAR TRIMURTI HANUMAN TEMPLE, ROOM NOS, CANGABA BAKARIWALI CHAWL, BHATWADI, CHATKOPAR WEST. MUMBAI - 400084 do hereby dectare and state a follows: - 1. Pancard Clubs Limited, the corporate debtor was, at the insolvency commencement date, being the Sth day ‘of September 2022, actually indebted to re for a sum of Rs 77120 2 In respect of my claim ofthe said sum or any part thereof. | have relied on the documents specified below: PAN CARD CLUB CERTIFICATE, PAN CARD CLUB RECEIPT, PAN CARD, AADHAR CARD, BANK PASSBOOK. 3. The said docurnents are true, valid and genuine to the best of my knowledge, information and belief anc no ‘material facts have baen concealed therefrom, 4. In respect ofthe said sum or any part thereof, neither |, 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 anc-except the ‘ollowing: NA ‘Slam nota related party ofthe corporate debtor, as defined under section 5 (24) of the Code, 6.Lam eligible to give vating instruction to the authorized representative by Virtue of proviso to section 21 (2) th Coca sag hcg rn velit par ofa opera ae 24 A _2 pate: 2-9(0 4leor2 deat ja Qalat ejue Place: uo (Signature of the claimant) VERIFICATION |, LAXMI VISHWAS CHOGARE the claimant hereinabove, do hereby verity that the contents ofthis proof of claim are true and correct to my knowledge and belief and no material fact has been concealed therefrom, seo Sin cris Pe ay gO oad a etch W241 et (Signature of claimant) 2 we [Note: In the case of company or limited liability partnership, the declaration and verification shall be made by the directorimanagerkecretaryidesigrated partner and in the case of other entitos, an officer authorized for the purpose by the entity] [Note: After downloading the fled in Form, the Upload & Claim is enabled for users) [Note: Before clicking Upload and Claim, please make sure to upload all necessary documents. 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