FORM No. I - Statement of unpaid or unclaimed dividend and interest thereon transferred to general revenue account of the Central Government - Companies Unpaid Dividend (Transfer to General Revenue Account of the Central Government) Rules, 1978

[1] [FORM No. I [See rule 4] The Companies Act, 1956 Registration No. ................. Nominal capital Rs. ................. Statement of unpaid or unclaimed dividend and interest thereon transferred to general revenue account of the Central Government [Pursuant to section 205A(6)] 1. Name of the company and address of its registered office. 2. Date of payment from the Company's Unpaid Dividend Account in the ............ to Punjab National Bank for credit to Central Government. 3. Particulars of the Challan under which paid into Punjab National Bank. 4. Financial year to which the dividend relates. Sl.No. Folio in register ledger containing particulars Name of the member to whom the amount of dividend is due (to be given in alphabetical order) Last known address of the person(s) entitled to receive the amount No. of shares held Equity Preference 1 2 3 4 5 6 Particulars of dividends Amount due Date of declaration Date of transfer to Un-paid Dividend Account On equity shares On preference shares Interest thereon, if any Total amount due and unpaid as per the company's unpaid dividend account in...... (Name of the Scheduled Bank) and the date of* payment into the Punjab National Bank Details of payment (Entries to be made by Registrar as and when payment is made by him) 7 8 9 10 11 12 13 Certified that whole of the amount remaining unpaid or unclaimed for a period of three years from the date of transfer to the special account under sub-sections (1) and (2) of section 205A has been transferred to the General Revenue Account of the Central Government. Total amount Rs. .................... (Sd.) *1. Secretary 2. Director 3. Director Dated this day ............. of ....... 19...... * To be signed by Secretary and one Director or at least by two Directors. --------------------------------------- Notes:- [1] Substituted by GSR 556(E), dated 2-9-1982, w.e.f. 3-9-1982.