FORM - Application for issue of immunity certificate under the Company Law Settlement Scheme (CLSS), 2010 - Company Law Settlement Scheme, 2010

FORM [Pursuant to Company Law Settlement Scheme, 2010] Application for issue of immunity certificate under the Company Law Settlement Scheme (CLSS), 2010 Note - All fields marked in are to be mandatorily filled. To The Registrar of Companies, Sir/Madam, I herewith make an application for issue of immunity certificate under the Company Law Settlement Scheme, 2010 and give below the following particulars, namely: 1. ( a ) Corporate identity number (CIN) or foreign company registration number (FCRN) of the company Pre-fill ( b ) Global location number (GLN) of company 2. ( a ) Name of the company ( b ) Address of the registered office or of the principal place of business in India of the company ( c ) e-mail ID of the company ( d ) Date of incorporation of Indian company or date of establishment of the principal place of business in India of foreign company (DD/MM/YYYY) 3. Details of documents filed under the Company Law Settlement Scheme, 2010 Pre-fill Total number of Service Request Number (SRN)(s) SRN Form number(s) Date of filing (DD/MM/ YYYY) Date of event (DD/MM/ YYYY) Statutory filing fees (in Rs.) Actual additional fees (in Rs.) Additional fee charged under CLSS, 2010 (in Rs.) Total fees paid (in Rs.) Total (in Rs.) 4. Whether any appeal(s) was filed against any notice issued or complaint filed before the competent court for violation of the provisions under the Act in respect of the above-mentioned document(s). If yes, attach proof of withdrawal of such appeal, Yes No Not applicable 5. Whether any prosecution(s) is pending in court against the company and its officers in respect of belated documents filed under the scheme. If yes, provide details thereof as an attachment. Yes No 6. Whether any director(s) of the company is declared as proclaimed offender or facing criminal case(s) for economic offences. If yes, provide details of such director(s) as an attachment. Yes No Attachments List of attachments 1. Proof of withdrawal of any appeal(s) against any notice issued or complaint filed before the competent court Attach 2. Details in respect of prosecution(s) pending against the company and its officers in respect of belated documents filed under the scheme which requires withdrawal by the Registrar Attach 3. Details of director(s) declared as proclaimed offender or facing criminal case(s) for economic offences Attach 4. Optional attachment(s) - if any Attach Remove Attachment Verification To the best of my knowledge and belief, the information given in this application and its attachments is correct and complete. o I have been authorised by the Board of directors resolution number dated (DD/MM/YYYY) to sign and submit this application. o I am authorised by the Board of directors to sign and submit this application. o The company had failed to comply with the provisions of the Act as mentioned in respect of filing of above-mentioned documents. o The company has withdrawn the appeals pending before any Court or Company Law Board or Regional Director or any other adjudicating authority. To be digitally signed by Managing Director or director or manager or secretary of the company (in case of an Indian company) or authorised representative (in case of a foreign company) Designation Director identification number of the director or Managing Director; or Income-tax permanent account number (Income-tax PAN) of the manager or authorised representative; or Membership number, if applicable or income-tax PAN of the secretary (secretary of a company who is not a member of ICSL may quote his/her income-tax PAN) Modify Check Form Pre-scrutiny Submit For office use only: Affix filing details e-Form Service request number (SRN) e-Form filing date (DD/MM/YYYY) Digital signature of the authorising officer This e-Form is hereby approved Confirm submission This e-Form is hereby rejected Date of signing (DD/MM/YYYY) nn