Form no. BEN-4

                                                                                                         [Pursuant to section 90(5) ofthe Companies Act, 2013 and rule 6]

                                                                                                                        [<<Insert Company Name>>] (the "Company'')

 <<Insert Date>>

 [By post/email]



Name and address of SBO/any other person


subject: Notice under sub-section (5) of Section 90 of the companies Act,20l3 and rules

 made there under

The Company has reasonable cause to believe that*

 - you are a significant beneficial owner of the company;

 -have knowledge ofthe identity ofsignificant beneficial owner of.......... .. ... . ....likely

   to have such knowledge;

 -have been a significant beneficial owner of the company during tbe three years

  immediatelv preceding the date of this notice, and


in respect of the above significant beneficial ownership the retum prescribed under Section 90

of the Act has not been filed in compliance with the Act.

You are accordingly advised to give the following information within 30 days of the date of

this notice in accordance with the section 90 of the Companies Act,2013 :


l. Name and Address of the Beneficial owner (B.o) (i.e. yourself or the significant BO if you are not the significant BO)

2. PAN of the B.O

3. Name of the person/entity/trust/body etc in whose name the shares/rights are registered/held

4. Folio number/DP and Client ID of the shares/securities

5. Nominal value of the shares/securities

6. Date of acquiring beneficial interest

7. Documents, terms and conditions or any other particulars regarding the BO ownership

8. Reason for not filing declaration in Form No. BEN-4.

9. Any other information incidental to or relevant or in your possession or knowledge to

    enable the company to evaluate this matter


The abovementioned particulars should be submitted in writing to the registered address of the

company not later than 30 days of the date of this notice failing which the company shall

proceed in the matter without further notice as per the provisions ofthe Act.

Name & signature

(Person authorized to issue notice)


*Delete whichever is not applicable