Registration No. of the Company
Nominal Capital: Rs
THE COMPANIES ACT, 1956

[pursuant to section 149(1)(d)]

[To be used by a company which issued a prospectus on

or with reference to its formation]

Name of the company
Limited
Presented by

I of being a director/the secretary of
Limited do solemnly

and sincerely declare:–

1. That the amount of the share
capital of the company offered to
the public for subscription is Rs..
2. That the amount stated in the
prospectus as the minimum
amount which, in the opinion of
the board of directors, must be
raised by the issue of share
capital in order to provide for the
matters specified in clause(5) of
schedule II of the Companies
Act, 1956, is Rs. ……………

3. That shares held subject held
subject to the payment of the
whole amount thereof in cash
have been allotted to the amount
of Rs. ………..
4. *That every director of the
company has paid to the
company on each of the shares
taken or contracted to be taken
by him , and for which he is liable
to pay in c ash a proportion
equal to the proportion payable
on application and allotment on
the shares offered for public
subscription* except the
following directors, namely
who has/have not taken or
contracted to take any shares for
which he is/they are liable to pay
in cash.
*That no director of the company
has taken or contracted to take
any shares for which he is liable
to pay in cash.
5. That no money is, or may
become liable to be repaid to
applicants for any shares or
debentures which have been
offered for public subscription by
reason of any failure to apply for,
or to obtain, permission for the
shares or debentures to be dealt

in on any recognised stock
exchange.
6. The statements in paragraphs
………………… above are true
to my knowledge and those in
the remaining paragraphs are
true to the best of my
information and belief.

Dated this . Day of . 19

Signature
Designation: Director/Secretary

*Delete paragraphs not applicable.