DECLARATION BY THE REGISTERED OWNER OF SHARES
Form MGT-4 · Section 89(1) read with Rule 9(1) of the Companies (Management and Administration) Rules, 2014
To,
The Board of Directors,
[Company Name]
CIN: [CIN]
I, [Registered Owner Name], resident of [Address], being the registered owner of the shares specified below, do hereby declare that I do not hold any beneficial interest in such shares and that the particulars of the beneficial owner are as under:
| Class of Shares | No. of Shares | Folio No. | Date of Becoming Registered Owner |
|---|---|---|---|
| [Equity/Preference] | [Number] | [Folio No.] | [DD/MM/YYYY] |
Particulars of the beneficial owner: Name [Beneficial Owner Name], Address [Address], PAN [PAN]. The nature of interest of the beneficial owner is [nature of interest] and the date on which such beneficial interest was created is [DD/MM/YYYY].
Signature: __________________
Name: [Registered Owner Name]
Name: [Registered Owner Name]
Place: [Place]
Date: [DD/MM/YYYY]
Date: [DD/MM/YYYY]