[Insert name of the company]

 

 

 

 

The issued share capital of the company

$

 

 

 

 

Shares of $

 

Divided into

 

Shares of $

 

 

 

Shares of $

 

Amount (if any) of above capital which consists of redeemable preference shares

 

Shares of $

 

The date on or before which these shares are, or are liable, to be redeemed

 

 

 

Names, descriptions, and addresses of directors or proposed directors

 

 

 

If the share capital of the company is divided into different classes of shares, the right of voting at meetings of the company conferred by, and the rights in respect of capital and dividends attached to, the several classes of shares respectively

 

 

 

Number and amount of shares and debentures issued within the two years preceding the date of this statement or proposed or agreed to be issued as fully or partly paid up otherwise than in cash

1.

2.

3.

shares of $   fully paid

shares upon which $    per share credited as paid

debentures $

 

The consideration for the issue or intended issue of those shares and debentures

4.

Consideration:

 

Number, description, and amount of any shares or debentures which any person has or is entitled to be given an option to subscribe for, or to acquire from a person to whom they have been allotted or agreed to be allotted with a view to his offering them for sale

1.

shares of $     and debentures of $

 

Period during which option is exercisable

2.

Until

 

Price to be paid for shares or debentures subscribed for or acquired under option

3.

$

 

Consideration for option or right to option

4.

Consideration:

 

Persons to whom option or right to option was given or, if given to existing shareholders or debenture holders as such, the relevant shares or debentures

5.

Names and addresses:

 

Names and addresses of vendors of property purchased or acquired, or proposed to be purchased or acquired by the company except where the contract for the purchase or acquisition was entered into in the ordinary course of the business intended to be carried on by the company or the amount of the purchase money is not material.

 

 

 

Amount (in cash, shares or debentures) payable to each separate vendor.

 

 

 

Amount (if any) paid or payable (in cash, shares or debentures) for any such property, specifying amount (if any) paid or payable for goodwill

Total purchase price  $ _______

Cash                      ... $

Shares                   ... $

Debentures            ... $ _______

Goodwill               ... $ _______

 

Short particulars of any transaction relating to any such property which was completed within the two preceding years and in which any vendor to the company or any person who is, or was at the time thereof, a promoter, director, or proposed director of the company had any interest direct or indirect

 

 

 

Amount (if any) paid or payable as commission for subscribing or agreeing to subscribe or procuring or agreeing to procure subscriptions for any shares or debentures in the company; or

Amount paid: $
Amount payable: $

 

Rate of the commission

 

per cent

 

Amount or rate of brokerage

 

 

 

The number of shares, if any, which persons have agreed for a commission to subscribe absolutely

 

 

 

Amount or estimated amount of preliminary expenses

$

 

 

By whom those expenses have been paid or are payable

 

 

 

Amount paid or intended to be paid to any promoter

Name of promoter:
Amount: $

 

Consideration for the payment

Consideration:

 

Any other benefit given or intended to be given to any promoter

Name of promoter:
Nature and value of benefit:

 

Consideration for giving of benefit

Consideration:

 

Dates of, parties to, and general nature of every material contract (other than contracts entered into in the ordinary course of the business intended to be carried on by the company or entered into more than two years before the delivery of this statement)

 

 

 

Time and place at which the contracts or copies thereof or (1) in the case of a contract not reduced into writing, a memorandum giving full particulars thereof, and (2) in the case of a contract wholly or partly in a language other than English, a copy of a certified translation thereof in English or embodying a translation in English of the parts in a language other than English, as the case may be, may be inspected

 

 

 

Names and addresses of the auditors of the company

 

 

 

Full particulars of the nature and extent of the interest, direct or indirect, of every director, and of every expert, in the promotion of or in the property proposed to be acquired by the company, or, where the interest of such a director or expert consists in being a partner in a firm or limited liability partnership or a holder of shares or debentures in a corporation, the nature and extent of the interest of the firm or limited liability partnership or corporation and where the interest of such a director or such an expert consists in a holding of shares or debentures in a corporation, a statement of the nature and extent of the interest of the director or expert in the corporation, with a statement of all sums paid or agreed to be paid to him or to the firm or limited liability partnership or corporation in cash or shares, or otherwise, by any person (in the case of a director) either to induce him to become, or to qualify him as a director or otherwise for service rendered by him or by the firm or limited liability partnership or corporation in connection with the promotion or formation of the company (in the case of an expert) for services rendered by him or the firm or limited liability partnership or corporation in connection with the promotion or formation of the company. For the purposes of this paragraph a director or expert shall be deemed to have an indirect interest in a corporation if he has any beneficial interest in shares or debentures of a corporation which has an interest in the promotion of, or in the property proposed to be acquired by the company or if he has a beneficial interest in shares or debentures in a corporation which is by virtue of section 6 of the Act deemed to be related to that first-mentioned corporation

 

 

 

 

 

 

Rates of the dividends, if any, paid by the company in respect of each class of shares in the company in each of the 3 financial years immediately preceding the date of this statement or since the incorporation of the company, whichever period is the shorter

 

 

 

Particulars of the cases in which no dividends have been paid in respect of any class of shares in any of these years.