Annexure

                                                                                                                                             Form No. BEN-I

                                                                                                 Declaration by the beneficial owner who holds or acquires significant beneficial

                                                                                                                                             ownership in shares

                                                                                                         [Pursuant to section 90(1) of the Companies Act, 2013 and rule 3(1)/3(2)]

To-

Name of the company:

Registered office address:

1. Particulars of the shares in which significant beneficial interest is held by the person making

 declaration:

        i) Class of shares:

       ii) Number and percentage of shares:

       iii) Shares/ securities in physical form

          -Distinctive numbers: From.......... To.,.........

          -Certificate No.:

          -Folio No.

       iv) Share/securities in Demat form

          -DP ID/ Client ID :

          -No. of shares:

          -Any other:

       v) Nominal value of shares:

       vi) Paid up value of shares:

2. Particulars of the holder of the significant beneficial interest

PAN*

SI. No.

Name of the Beneficial Owner

Address and E-

mail id

Date of Birth/ Age

Father's/

Mother's/

Spouse's name

(1)

(2)

(3)

(4)

(5)

Occupation

Nationality

CIN (in case of

 company)

Passport No.

(in case of

foreign

national)

 

(6)

(7)

(8)

(9)

 

 3. Declaration

 In pursuance of sub-section (l) of section 90 of the Companies Act 2013, I

 ................hereby declare that I hold / have acquired a significant beneficial

 interest in the above mentioned shares ofthe company which are registered in the name of the

 person whose particulars are fumished below:

 4. Particulars ofthe registered owner

PAN*

SI. No.

Name of the Beneficial Owner

Address and E-mail id

Date of Birth/ Age

Father's/

Mother's/ Spouse's name

(1)

(2)

(3)

(4)

(5)

Occupation

Nationality

PAN/UIN/CIN (in case of company)

Passport No. (in case of foreign national)

 

(6)

(7)

(8)

(9)

 

5. Details of the significant beneficial interest:

 i) Date of creation / acquisition of signific4nt beneficial interest:

 ii) Mode of acquisition of significant beneficial interest: Allotment lTransfer / others,

specify

iii) Nature ofi the significant beneficial interest:

iv) Reasons lor not registering shares in my name:

v) Particulars ofthe instrument/document, ifany, showing the creation of such significant

 beneficial interest:

vi) Direct/ Indirect percentage of voting rights:

6. Particulars of the person from whom the significant beneficial interest is acquired, if

 applicable:

 i) Name ofthe transferor of significant beneficial interest:

 ii) Whether shares were registered in bis name:

 (lf not, whefher any dcclaration under sub-section (2) ofsection 89 was filed by him to the

 company, If so, date of such declaration)

 iii) Pnrticulars of the instrument/ document, if any, showing the transfer of such significant beneficial interest:

Date:

Place:

Signature of the holder of the significant beneficial interest

CERTIFICATE

 I hereby certify that the significant beneficial interest in the shares mentioned above has been

 transferred by me on...........................

Signature of the person who has transfened the significant beneficial interest in the shares

Date:

Place:

Enclosures:(a) Proof o fidentity oft he registered owner and holder ofthe significant beneficial

 interest

(b) Instrument/ document under which the significant beneficial interest is created/ transfened/

changed

Form No. BEN-2

Return to the Registrar in respect ofdeclaration under section 90 received by company

lPursuant to section 90(4) of the Companies Act, 2013 and rule 4]

O For Significant beneficial ownership O For Change in Significant beneficial ownership

Total percentage

 

 

                                                                          O Date of Change .

                                                                          O SRN of BEN-2 latest(last) filed for significant beneficial

                                                                                                                 

 

                                                                               Ownership

                                                                               Total percentage ... . . . .. ..

                                                 

l. (a) CIN:

(b) GLN:

 2. (a) Name of the company:

(b) Registered office address:

(c) E-mail id:

 3. Particulars of significant beneficial interest:

PAN *  

 Prefill

S. No

Date of declarations .

Date of receipt of

Particulars of shares in respect of which beneficial interest is created

 

 

under subsection (l) of section 90

the said declarations by the company

Class of shares

No. of shares

Distinctive Nos. of shares/ DP and Client ID of shares

 

(1)

(2)

(3)

(4)

(5)

(6)

 

Particulars of shares in respect of which beneficial interest is created

Particulars of registered owner

 

Face value of shares

Paid up value of shares

Name of the registered owner

Addres s and email id

Date of Birth/ Age

Father' s/ Spouse 's name

Occu patio n

 

(7)

(8)

(9)

(10)

(11)

(12)

(13)

 

Particulars of registered owner

Particulars of beneficial owner

 

Nationality

PAN/UIN/ CIN (in case of company)

Passport No. (in case of foreign national)

Name & Nationality

Address and e-mail id

 

(14)

(15)

(16)

(17)

(18)

 

 

Date and Nature of beneficial interest

Remarks

 

Father's/ Spouse's Name

 

(19)

(20)

(21)

Date:

 Place:

 Attachments: I . Declaration under section 90 (1); 2. Optional attachments, if any

 

 Form no. BEN-3

                                                                                 Register of beneficial owners holding significant beneficial interest

                                                                               [Pursuant to section 90(2) of the Companies Act, 201 3 and rule 5(l)]

Name of the company:

Registered office address:

     l. Particulars of fte beneficial owner holding significant beneficial interest

PAN *  

 Prefill

Sl. No.

Name of the Beneficial owner

Address and Email id

Date of Birth/ Age

Father's/ Mother's/ Spouse's name

(1)

(2)

(3)

(4)

(5)

Occupation

Nationality

PAN/UIN/CIN (in case of company)

Passport No. (in case of foreign national)

Status

(6)

(7)

(8)

(9)

( 10)

Date of declaration under section 90

Date of cessation

Date of entry in Register

Date of filing of BEN-2(SRN wise)

Amount of guarantee, if any

(11)

(12)

 

 

 

Any other interest, if any

Instructions, if any, given by the member wt

 

 

 

2. Particulars of the shares in which significant beneficial interest is held by the beneficial owner:

 i) Class of shares:

 ii) Number of shares:

 iii) Shares/ seeurities in physical form

     -Distinctive numbers: From.......... To........

     -Certificate No.:

     -Folio No.

 iv) Shares/ securities in Demat form

    -DP ID/ Client ID :

    -No. of shares

   -Any other:

v) Nominal value of shares:

vi) Paid up value of shares:

 

 

                                                                                                                                             Form no. BEN-4

                                                                                                         [Pursuant to section 90(5) ofthe Companies Act, 2013 and rule 6]

                                                                                                                        [<<Insert Company Name>>] (the "Company'')

 <<Insert Date>>

 [By post/email]

 

To:

Name and address of SBO/any other person

Date:

subject: Notice under sub-section (5) of Section 90 of the companies Act,20l3 and rules

 made there under

The Company has reasonable cause to believe that*

 - you are a significant beneficial owner of the company;

 -have knowledge ofthe identity ofsignificant beneficial owner of.......... .. ... . ....likely

   to have such knowledge;

 -have been a significant beneficial owner of the company during tbe three years

  immediatelv preceding the date of this notice, and

 

in respect of the above significant beneficial ownership the retum prescribed under Section 90

of the Act has not been filed in compliance with the Act.

You are accordingly advised to give the following information within 30 days of the date of

this notice in accordance with the section 90 of the Companies Act,2013 :

 

l. Name and Address of the Beneficial owner (B.o) (i.e. yourself or the significant BO if you are not the significant BO)

2. PAN of the B.O

3. Name of the person/entity/trust/body etc in whose name the shares/rights are registered/held

4. Folio number/DP and Client ID of the shares/securities

5. Nominal value of the shares/securities

6. Date of acquiring beneficial interest

7. Documents, terms and conditions or any other particulars regarding the BO ownership

8. Reason for not filing declaration in Form No. BEN-4.

9. Any other information incidental to or relevant or in your possession or knowledge to

    enable the company to evaluate this matter

 

The abovementioned particulars should be submitted in writing to the registered address of the

company not later than 30 days of the date of this notice failing which the company shall

proceed in the matter without further notice as per the provisions ofthe Act.

Name & signature

(Person authorized to issue notice)

 

*Delete whichever is not applicable