Annexure A - Return on Buy-Back of Securities - Private Limited Company and Unlisted Public Limited Company (Buy-back of Securities) Rules, 1999

Annexure A (See rule 9) Companies Act, 1956 [Pursuant to section 77A (10)] Return on Buy-Back of Securities 1. Name of the Company. 2. Address of Registered Office : 3. Registrar of Companies : Registration Number : 4. Income Tax PAN No. : 5. Details of capital as on ............................ Sl.No. Details of Capital Authorised Capital Subscribed Capital Paid-up Capital 1. Equity 2. Preference 3. Redeemable Preference 4. Employees' tock Option 5. Sweat Equity 6. Others Total 6. Free Reserves (as defined in clause ( b ) of Explanation to section 372A) As on ..................... 7. Securities Premium Account ...... as on .................. 8. Proceeds of any shares or other specified securities ..... as on ....... 9. Debts: As on ................ A. Secured B. Unsecured C. Total 10. Date of Member's Special Resolution authorising buy-back of securities. 11. Amount of buy-back authorised. 12. Date up to which buy-back authorised to be completed. 13. Date on which earlier buy-back was authorised. 14. Date on which the earlier buy-back was completed. 15. Debt Equity Ratio allowed for the company. 16. Details of Government approval for Debt Equity Ratio higher than 2:1. 17. Whether there is any default in: A. Repayment of deposit. Yes/No B. Repayment of interest payable on "A" above Yes/No C. Repayment of debentures Yes/No D. Repayment of Preference Shares. Yes/No E. Payment of dividend to Shareholders. Yes/No F. Repayment of Term Loans to any Financial Institution/Bank. Yes/No G. Repayment of interest on the "F" above Yes/No 18. Whether there is any default in complying with: A. Section 159 (Annual Return) B. Section 207 (Payment of Dividend) C. Section 211 (Balance Sheet/Profit and Loss Account) 19. Description of securities bought-back by the company: Sl.No. Folio No./Certificate No. of security bought-back Date of Buy-back No. of securities bought-back Sweat, etc.) Category to which they belong (Preference/Equity/Employees' Stock Option/ Name of the last holder of of security Reference to entry in Members' Register (1) (2) (3) (4) (5) (6) Mode of acquisition a/b/c/d/e* Face value of security Buy-back value paid for security Total Consideration paid for Buy-back Cumulative total of col. (9) Date of cancellation of security Remarks (7) (8) (9) (10) (11) (12) (13) * a from the existing security-holders on a proportionate basis b from the open market c from odd-lots of listed securities d from Employees' Stock Option e from Sweat Equity 20. Date of extinguishment of securities. 21. Date of physical destruction of securities. Signature: ..................... Name: .......................... Place: .............. Designation: .................. Date: ................ Company Seal