FORM-I
[see rule 6(1)]
To
The Chairperson
Haryana Micro and Small Enterprises Facilitation Council
Panchkula
Subject: Reference under Section 18 of the Micro, Small and Medium Enterprises Development (MSMED)
Act, 2006.
I am authorized representative of M/s------------------------------. This firm is a micro/ small unit as per provisions of
MSMED Act, 2006. This unit had supplied the goods/ services to M/s----------------------------------, but it has not been
paid as per provisions of Section 15 of MSMED Act, 2006. I, therefore, aggrieved with the buyer, wish to file a
reference. The information pertaining to case is as under:
1. Udyog Aadhar No./ Udyam Registration No.:
(Proof to be attached)
2. Haryana Udhyam Memorandum No :
(Proof to be attached)
3. Date of filing application (DD/MM/YYYY):
4. Details of aggrieved MSE
4.1 Name of Authorized representative:
(authorization to be attached)
4.2 Name of Enterprise (supplier):
4.3 Address (including Pin code):
4.4 District:
4.5 State:
4.6 Mobile No.:
4.7 Email:
4.8 Type of aggrieved Enterprise:
Micro Small
5. Name of respondent (buyer)
5.1 Address (including Pin code):
5.2 District:
5.3 State:
5.4 Mobile No.:
5.5 Email:
5.6 Category of respondent (buyer) [CPSU/State PSU/--------]:
6 Details of information in respect of claim
(1) Details of purchase orders issued by the purchaser/Respondent with description of
material/Service provided quantity and cost along with photocopies.
(2) Detailed description of mutually agreed terms and conditions between purchaser and supplier
/Agreement / Contract along with stipulated delivery date.
(3) Details of Invoices/Bills raised against purchase order with particulars of material /service name,
quantity and cost along with photocopies.
(4) Details of delivery challans /work completion certificates/goods receipt along with photocopies.
(5) Details of material/services acceptance, quantities and date along with photocopies.
(6) Details of paid and unpaid invoices with dates in the order of supplies.
(7) Details of completion of forty-five days and appointed day for calculating delayed payment for
goods/ services supplied.
(8) Details of correspondence with Respondent for payment of outstanding dues.
(9) Details of complaints/objections of Respondent, if any, against goods supplied/services provided
or any understanding between parties and proof thereof.
(10) If a complaint is received from Respondent on supplied goods and services or on mutual
agreement, then acceptance of the same by Respondent buyer after rectification/ replacement with
date and proof thereof.
7. Principal amount payable:
8. Interest claimed as on:
(Attach calculation sheet as per Form-II)
9. Details of fee paid:
9.1 Amount:
9.2 Mode: Cheque/ Demand Draft/ NEFT (Provide details)
10. Relief Sought
11. Any other relevant information and brief description (Case History)
12. Additional Documents to be submitted:
(a) Audited Balance Sheet and Ledger for the relevant financial years;
(b) Photocopy of Udyog Aadhaar Memorandum/ Udyam Registration Number;
(c) Photocopy of Haryana Udhyam Memorandum;
(d) Affidavit in support of application.
I hereby declare that information given above is true to the best of my knowledge. Any information that may
further be required, shall be provided immediately before the concerned authority.
Signature:
Name :
Date: (Authorized signatory on behalf of aggrieved MSE)
INSTRUCTIONS:
1. Claim application is required to be filed on MSME Samadhaan portal of Government of India on
[Link] ;
2. Printed original copy of the claim application must be submitted to the Council after fifteen days of filing
claim on MSME Samadhaan portal. The claim application must be supported by an affidavit in case purchase
order is oral;
3. All annexure(s) to the claim application must be self-attested;
4. List of documents duly mentioning the page number in chorological order shall be enclosed along with the
claim application;
5. Copies of claim application must be in proportion to the number of the respondents along with one original
copy;
6. Incomplete claim application shall not be accepted.
Form-II
[see rule 6(1)]
INTEREST CALCULATION
Sr. Invoice/ Total Date of Amount of Delay Principal Details of bills with Due date/ 45 days for Calculation of Interest of Calculation of Remarks
No. Bill Nos. amount of receipt of Payment Period amount bill no. and date on payment, as the case interest on Bank rate Compound interest with
and Date Invoice/ Goods/ received with remaining which interest has may be, from the date delayed/ unpaid as monthly interest as
of Bills Services date against unpaid been claimed of purchase order/ payment in terms Notified three times of the Bank
Supply indicated by Buyer goods supplied/ agreement or as of Act/ agreement by the Rate notified by the
order in Column service provided in the Act from the date of Reserve Reserve Bank of India
(2) provided for calculating the appointed day till Bank of (as indicated in column
Invoice Amount actual date of the date of filing India (12) for the period
/ Bill appointed day the reference from ________ to
Nos. before the Council ________ of
interest with monthly
interest as three times of
the Bank Rate notified
by the Reserve Bank of
India (as indicated in
column (12) for the
period from
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14)
1.
2.
3.
4.
5.
Signature: _________
Name: ________
Date: (Authorized signatory on behalf of aggrieved MSE)
Form-III
[see rule 6(1)]
(Undertaking to be submitted by the claimant supplier under MSMED Act, 2006 on the letter head of the
enterprise)
To
The Chairperson
Haryana Micro and Small Enterprises Facilitation Council
Panchkula
Subject: Reference under Section 18 of the Micro, Small and Medium Enterprises Development (MSMED) Act,
2006.
I am authorized representative of M/s------------------------------. This firm is a micro/ small unit as per provisions of
MSMED Act, 2006. I hereby confirm that this firm has not moved any reference before any Civil Court on the present
dispute.
I, hereby, declare that the information given above is true to the best of my knowledge and belief.
Signature:
Name:
Date: (Authorized signatory on behalf of aggrieved MSE)