FORM NO. CAA.1

[Pursuant to section 230(2)(c)(i) and    rule 4]

Creditor’s Responsibility Statement

I/ We, …………………, the creditors of M/s…………… for an amount of Rs. ……………. as on ……………… do hereby declare that I / we have read and understood the proposed corporate debt restructuring scheme and am / are of the view that it is in my/our best interest to concur with the scheme.

I/ We further declare that the debt is owed to me / us by the company or the liability was created by the company in my/ our favor in good faith and in the ordinary course of business of the company;

I/We believe that the scheme does not give me/us any fraudulent preference at the cost of any secured/unsecured Creditors.

Signature of creditor/s

Date:

Place: