FORM No. II - Application to the Central Government for an order for payment of the dividend amount out of the General Revenue Account of the Central Government Pursuant to section 205B of the Companies Act, 1956 - Companies Unpaid Dividend (Transfer to General Revenue Account of the Central Government) Rules, 1978

FORM No. II [See rule 6(1)] PART 'A' Application to the Central Government for an order for payment of the dividend amount out of the General Revenue Account of the Central Government Pursuant to section 205B of the Companies Act, 1956 1. Name of the applicant: 2. Postal address of the applicant: 3. Name, registration number and registered address of the company from which the amount is due: 4. Number of shares held: (i) Preference shares *(with distinctive numbers) (ii) Equity shares (with distinctive numbers). 5. Financial year to which the dividend relates; 6. Amount due: (i) On preference shares (ii) On equity shares (iii) Interest, if any, payable to him pursuant to sub-section (4) of section 205A of the Act, and (iv) Total of (i), (ii) and (iii) above: 7. Reasons for non-receipt of the amount from the company: Place Date ................................................... (Signature of the applicant or a person holding a power of attorney, from the applicant). [1] [Received from the Registrar of Companies ................... the sum of Rs. ........... (Rupees ......................... in words) being the amount payable to me/us from the General Revenue Account of the Central Government as unclaimed or unpaid dividend (which was originally) due from M/s. ......................... 1. Signature of witness, with name, date, address and occupation.. Signature of the claimant with name, date, address and occupation. 2. Signature of witness. with name, date, address and occupation (on revenue stamp of 20 paise, if the claim is for Rs. 20 or more). Notes: 1. Indemnity bond should be furnished on a non-judicial stamp paper of the requisite value, in case the claim exceeds [2] [Rs. 2,500]. 2. In the case of deceased shareholder, the legal representative(s) of the deceased shareholder, who is (are) preferring the claim, is (are) required to furnish succession certificate/probate/letters of administration. In case the charge have been transmitted in the name of the claimant, a certificate in this behalf from the company be furnished. 3. Dividend warrant or a photo-copy of the share certificate should be furnished. 4. Separate applications should be made for claims in respect of each company]. PART 'B' Payment Order by the Registrar Certified that the amount claimed, namely, Rs. .................................. has actually been deposited by the company to the General Revenue Account of the Central Government under Major Head "068 Miscellaneous General Services Unpaid Dividends of Companies" on ........................................ (date) Necessary note for refund has been kept in the accounts maintained by me. Classification "068 Miscellaneous General Services Unpaid Dividends of Companies Deduct Refunds". (Registrar) Passed for payment for Rs. ................... in favour of Shri ...................... The cheque/demand draft may please be issued in favour of Shri .............................. (Registrar) ------------------------------------- Notes:- [1] Inserted by GSR 363(E), dated 7-3-1988. [2] Substituted by GSR 136(E), dated 1-3-1989.