[Pursuant to section 232(7) and rule 21]

In the Matter of compromise and / or arrangement of …………………

Statement to be filed with Registrar of Companies

1. (a) Corporate identity number (CIN) of company:

(b) Global location number (GLN) of company:

2. (a) Name of the company:

(b) Address of the registered office of the company:

(c) E-mail ID of the company:

3. Date of Board of Directors’ resolution approving the scheme

4. Date of Order of Tribunal approving the Scheme under Section 232(3)

5. Details regarding:-

a) Completed actions under the Order

b) Pending actions under the Order with status

Declaration of compliance of scheme as per the Order of the Tribunal

I, the Director / Company Secretary of …………………. do solemnly affirm and declare that we are in compliance with the Order of the Tribunal dated ________.

A copy of the scheme of the compromise or arrangement is enclosed.

__________________

Director / Company Secretary

__________________

Chartered Accountant in practice / Cost Accountant in practice / Company Secretary in practice

Date:

Place:

Attachments :-

1) Scheme of Compromise or Arrangement

2) Details of Compliance of the Scheme

3) Other Attachments, if any