Form No. MGT-4
Declaration by the registered owner of shares who does not hold the beneficial interest in such shares
[Pursuant to section 89(1) of the Companies Act, 2013 and rule 9(1) of the Companies (Management and Administration) Rules, 2014]
To
(The Company)
Adders ————————–
1. Particulars of the Registered owner of shares:
(i) Name : ———————-
(ii) Father’s / Mother’s / Spouse’ name: ——————
(iii) Occupation :———————
(iv) Whether citizen of India: ——–
(v) Nationality : ————–
(vi) Date of Birth:————-
(vii) Gender: ————
(viii) PAN No. :—————
(ix) Proof of Identity :
For Indian Nationals :
(Any of the following):
√ Income-tax permanent account number
> Voter’s identity card number
> Passport number
> Driving License
√ Unique Identification Number (Aadhar Card)
For Foreign nationals and Non Resident Indians : NA
> Passport
> Others
(x) Permanent Residential Address: ————————————–
ISO Country Code: —- Country : ——–
Phone: Mobile: Fax:
Email ID : ———————————–
(xi) Whether present residential address is same as the permanent residential address : ———
If no, present residential address :NA
| ISO Country Code: | Country : |
| Phone: | Mobile : |
| Fax: | Email ID : |
2. Particulars of the shares in respect of which declaration is being made by the registered owner:
i) Class of shares: ————–
ii) Number of shares: —————-
iii) Distinctive numbers: —————
iv) Certificate No.: —-
v) Folio No.: ——-
vi) Nominal value of shares: Rs. —
vii) Paid up value of shares: Rs. —
3. Declaration:
In pursuance of sub-section (1) of section 89 of the Companies Act, 2013, I ________ hereby declare that the person(s) name mentioned below hold(s) the beneficial interest in the above mentioned shares registered in my name in the register of members of the company:
| Sl. No. | Name of the beneficial owner (s) | Address and E-Mail ID | Date of birth /Incorporation | Father’s /Spouse’s name |
| (1) | (2) | (3) | (4) | (5) |
| 1. | ||||
| Occupation | Nationality | PAN/ UIN/ CIN (In case of Company) | Passport No (In case of foreign national) | Distinctive No., if applicable |
| (6) | (7) | (8) | (9) | (10) |
4. Details of the beneficial interest:
i) Nature of the beneficial interest: ———–
ii) Date of creation of the beneficial interest: ————
iii) Reasons for not registering shares in the name of the beneficial owner(s): —————————————.
iv) Particulars of the instrument/ document, if any, showing the creation of such beneficial interest: ————————————————–
5. Particulars of change in beneficial interest: NA
i) Date of change:
ii) Nature of the change in the beneficial interest:
iii) Brief particulars of such change:
iv) Reason for such change:
v) Particulars of the instrument/ document, if any, showing the change in such beneficial interest:
Date: —
Place: —
Signature of the registered owner:
(——————-)
Enclosures:
(a) Proof of identity of the registered owner and beneficial owner
(b) Instrument/ document under which the beneficial interest is created/ transferred.
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