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

[pursuant to section 149(2)©]

(To be used by a company which has delivered to the
Registration of a Companies a statement in lieu of prospectus.)

Name of the company
Limited
Presented by

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

and sincerely declare:–

1. The amount of the share capital of the company subject
to the payment of the whole amount thereof in cash is
Rs.
2. That the company has not issued a prospectus inviting
the public the subscribe for its shares, and that it has
filed with the Registrar a statement in the lieu of
prospectus.
3. That shares held subject to the payment of the whole
amount thereof in cash have been allotted to the
amount if 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

cash, a proportion equal to the proportion payable on
application and allotment on the shares payable in cash
expect 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. The statement in paragraphs above are true
to my knowledge and those in the remaining are true to
the best of my information and belief.

Dated this Day of 19

Signature

Designation: Director/Secretary

*Delete paragraphs not applicable.