Form No. MGT-4 Declaration by registered owner of shares not holding beneficial interest

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

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:

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.