FORM “A” - Declaration under the Company Law Settlement Scheme, 2000 Form of Declaration - Company Law Settlement Scheme, 2000

FORM A Declaration under the Company Law Settlement Scheme, 2000 FORM OF DECLARATION To The Registrar of Companies, Sir/Madam, I/We herewith make a declaration under the Company Law Settlement Scheme, 2000 and give below the following particulars, namely:- 1. Name of the declarant and Address : (in Block letters) 2. Name of the Company : 3. Registration No. of company : 4. Date of incorporation of the company : 5. Address of the Company : 6. Status of the company : whether public/private If public Listed/Non-listed 7. Business /objects of the company : (Tick in appropriate column) - Manufacturing ------------------------ - Trading ------------------------ - Finance ------------------------- - Service --------------------------- - Others (please specify)-------------------- 8. Statement of Declaration of non-compliance Sl. No. Nature of return to be filed Section under which to be filed Status of offence (whether still Continuing) 9. Sl. No. Nature of document Due date of Period of delay filing Amount payable under Company Law Settlement Scheme 2000 (Rs.) Details of payment (a) Demand Draft No. (b) Date (c) Name of Bank (d) Amount (Rs.) Company Registration No. Signature of the Managing Director/Whole TimeDirector/Director/Manager/Company Secretary 10. Whether declarant on behalf of the company would like to be granted immunity for non-compliance?------------------------------- 11. Submission : In light of the circumstances herein mentioned above and keeping in mind the admission of the offence by the applicant/company and taking into consideration the nature, scope, extent, seriousness, gravity of the offence, the applicant/company, himself requests for the grant of immunity in the form of relief for non-compliance. 12. List of enclosures. Designation/Signature of the applicant Date: Place: (Seal of the declarant) VERIFICATION I, son/daughter/wife of Shri in my capacity as in the company, solemnly declare that- (a) the information given in this declaration is true to the best of my knowledge and belief. (b) The company had failed to comply with the provisions of the Companies Act, 1956 as mentioned above. (c) I have withdrawn the appeals pending before Court/Company Law Board/Regional Director or other adjudicating authority: I further declare that this declaration is in my capacity as the Managing Director/Director and that I am competent to make this declaration and verify it. Date: Place: Designation/Signature of the applicant (Seal of the declarant) CERTIFICATE GRANTING IMMUNITY FROM PENALTY AND PROSECUTION UNDER THE COMPANY LAW SETTLEMENT SCHEME, 2000 Whereas----------------- (hereinafter referred to as the company) had made a declaration under the Company Law Settlement Scheme, 2000, and had filed the documents mentioned below along with the declaration and also paid the compounding fee of Rs.----------------- payable as per the said declaration: Sl No. Nature of return to be filed Section under which to be filed And whereas the applicant had also declared that no petition or appeal before any Court/Company Law Board/Regional Director against any notice or order in respect of the fine payable has been filed by such applicant/had withdrawn such appeal/writ petition from the Court/Company Law Board/Regional Director. Now, therefore, in exercise of the powers conferred under this scheme, the undersigned hereby issues this certificate to the said company to: (a) certify receipt of payment from the declarant towards full and final settlement of the compounded fee payable under this scheme: (b) grant immunity subject to the provisions contained in the scheme from instituting and proceeding for prosecution for any offence under the Companies Act, 1956, or from the imposition of penalty under the said enactment for the time being in force in respect of the matters covered in the aforesaid declaration made by the declarant Date: Place: Designated Authority