Form No. 04A - Declaration of solvency - Companies (Central Government’s) General Rules and Forms, 1956

[1] [Form No. 04A (See rule 5C) Declaration of solvency Name of the Company: .................................................................... Address (Regd. Office): .................................................................... .................................................................... .................................................................... .................................................................... Presented by: ................................................. (Name) ................................................ (Designation) We, .......................................................... of ......................................... and of ............................. being all the directors of M/s. ....................................... do solemnly affirm and declare that we have formed the opinion that the company is capable of meeting its total liabilities and that the company will not be rendered insolvent within a period of one year from the date of making this declaration. We append a statement of company's assets and liabilities as at ........... being the latest date before making of this declaration (Annexure-I). We further declare that the company's audited annual accounts including the Balance Sheet have been filed upto date with the Registrar of Companies .. Signature ...................................... Name ...................................... Managing Director Signature ...................................... Name ...................................... Directors Signature ...................................... Name ...................................... Directors Verification And we make this solemn declaration believing the same to be true. We solemnly declare that we have made a full enquiry into the affairs of the company including assets and liabilities of this company and that having done so and having noted that the shareholders by a special resolution have approved the buy-back of .................. (............. ................) (in words) number of shares/securities as per the provisions of section 77A of the Companies Act, 1956, as inserted by the Companies (Amendment) Ordinance, 1999 (1 of 1999) Verified this day the ........................... day of ..................., 19.......... Signature ...................................... Name ...................................... Managing Director Signature ...................................... Name ...................................... Directors Signature ...................................... Name ...................................... Directors Solemnly affirmed and declared at ................ the ................ day of ................., 19............ before me. Commissioner for Oaths and Notary Public or Justice of the Peace Annexure I Statement of Assets and Liabilities Statement as at .................... 19......., showing assets at estimated realisable values and liabilities expected to rank. Name of the Company: ............................................................ Assets Book Value Estimated to realise 1. Balance at Bank 2. Cash in hand 3. Marketable Securities 4. Bills Receivables 5. Trade Debtors 6. Loans and Advances 7. Unpaid Calls 8. Stock-in-trade 9. Work in Progress viz .................... .................... .................... 10. Freehold Property 11. Leasehold Property 12. Plant and Machinery 13. Furniture, fittings, utensiles, etc. 14. Patents, Trade Marks, etc. 15. Investments other than Marketable Securities 16. Other property viz. .................... .................... .................... Total: Liabilities Estimated to rank for payment (to the nearest rupee) 1. Secured on specific assets viz; ............................................ 2. Secured by floating charge(s), viz; ............................................ 3. Estimated cost of liquidation and other expenses including interest accruing until payment of debts in full. 4. Unsecured creditors (amounts estimated to rank for payment) (a) Trade accounts (b) Bills payable (c) Accrued expenses (d) Other liabilities ............................................ ............................................ ............................................ ............................................ (e) Contingent liabilities ............................................ ............................................ ............................................ ............................................ Total: Total estimated value of assets Rs. ................ Total Liabilities Rs. ................ Estimated surplus after paying ...................... debts in full Rs. ............... ...................... Remarks Signature ...................................... Name ...................................... Managing Director Signature ...................................... Name ...................................... Directors Signature ...................................... Name ...................................... Directors Place: ...................... Date: ....................... * The period to be filled in should not exceed 3 years". -------------------------------------- Notes:- [1] Inserted by the Companies (Central Government's) General Rules Forms (Amendment) Rules, 1999, w.e.f. 12-1-1999.