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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*
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SI. No.
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Name of the Beneficial Owner
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Address and E-
mail id
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Date of Birth/ Age
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Father's/
Mother's/
Spouse's name
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(1)
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(2)
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(3)
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(4)
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(5)
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Occupation
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Nationality
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CIN (in case of
company)
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Passport No.
(in case of
foreign
national)
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(6)
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(7)
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(8)
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(9) |
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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*
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SI. No.
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Name of the Beneficial Owner
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Address and E-mail id
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Date of Birth/ Age
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Father's/
Mother's/ Spouse's name
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(1)
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(2)
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(3)
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(4)
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(5)
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Occupation
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Nationality
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PAN/UIN/CIN (in case of company)
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Passport No. (in case of foreign national)
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(6)
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(7)
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(8)
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(9)
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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 *
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S. No
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Date of declarations .
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Date of receipt of
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Particulars of shares in respect of which beneficial interest is created
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under subsection (l) of section 90
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the said declarations by the company
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Class of shares
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No. of shares
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Distinctive Nos. of shares/ DP and Client ID of shares
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(1)
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(2)
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(3)
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(4)
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(5)
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(6)
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Particulars of shares in respect of which beneficial interest is created
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Particulars of registered owner
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Face value of shares
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Paid up value of shares
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Name of the registered owner
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Addres s and email id
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Date of Birth/ Age
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Father' s/ Spouse 's name
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Occu patio n
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(7)
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(8)
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(9)
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(10)
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(11)
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(12)
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(13)
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Particulars of registered owner
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Particulars of beneficial owner
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Nationality
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PAN/UIN/ CIN (in case of company)
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Passport No. (in case of foreign national)
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Name & Nationality
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Address and e-mail id
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(14)
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(15)
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(16)
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(17)
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(18)
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Date and Nature of beneficial interest
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Remarks
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Father's/ Spouse's Name
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(19)
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(20)
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(21)
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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 *
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Sl. No.
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Name of the Beneficial owner
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Address and Email id
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Date of Birth/ Age
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Father's/ Mother's/ Spouse's name
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(1)
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(2)
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(3)
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(4)
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(5)
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Occupation
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Nationality
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PAN/UIN/CIN (in case of company)
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Passport No. (in case of foreign national)
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Status
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(6)
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(7)
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(8)
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(9)
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( 10)
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Date of declaration under section 90
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Date of cessation
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Date of entry in Register
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Date of filing of BEN-2(SRN wise)
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Amount of guarantee, if any
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(11)
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(12)
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Any other interest, if any
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Instructions, if any, given by the member wt
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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
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