(a)

Name of the applicant company/society/partnership firm/trust

(b)

Address

(c)

Place of incorporation/registration

(d)

Date of incorporation/registration

(e)

Total issued and paid-up capital

:

(In case of company/society)

Total capital of partners

:

(In case of partnership firm)

Brief details of corpus

:

(In the case of Trust)

Name of shareholder of the company/partner of the firm/member of the society/beneficiary of the trust

Country of residence

Nationality

Company/
Society

Partnership Firm

Trust

Paid-up value of shares held

Perce-ntage holding

Capital owen-ed

Profit sharing ratio

Extent/percentage of beneficial interest in the corpus

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

1.

Persons of Indian nationality and/or origin

(1)

(2)

II.

Others

(1)

(2)

Total of I & II

I/We hereby certify that I/we have verified the register of shareholders or

members/partnership deed/trust deed and the relevant books and records of .........(name of the company/society/partnership firm/trust) and that the information and particulars given hereinabove are in accordance with such books and records maintained by it and are true and correct to the best of my/our knowledge and belief.

I/We also certify that the ownership interest of individuals of Indian nationality / origin

resident outside India in the abovementioned company / society / firm is.........per cent of the total ownership interest as on ..........(date).

I/We further certify that the ownership interest held by persons of Indian nationality/origin

in the OCB is actually held by such persons and is not held by them in the capacity as nominees.

Note:

In the case of trust, the certificate should indicate the extent/percentage of beneficial interest in the trust held irrevocably by individuals of Indian nationality/origin resident outside India.

.............................................................................

Place

:

.................

Stamp

(Signature of Auditor/Chartered Accountant/ Certified Public Accountant)

Date

:

.................

Name:

....................................................................

Address :

...........................................................

Registration No. :

...................................................

Notes:

(i)

Please strike out whichever is not applicable.

(ii)

For the purposes of this certificate, a person (not being a citizen of Pakistan or Bangladesh) shall be deemed to be of Indian Origin, if (a) he, at any time, held Indian passport, or (b) he or either of his parents or any of his grand parents was a citizen of India by virtue of the Constitution of India or Citizenship Act, 1955 (57 of 1955). A spouse (not being a citizen of Pakistan or Bangladesh) of an Indian citizen or of a person of Indian origin is also deemed to be a person of Indian origin.

(iii)

Where the ownership/beneficial interest of each person is less than 10%, owner/beneficiary-wise particulars as per columns (1) to (8) of the above statement need not be furnished. It would be sufficient if in such cases aggregate figures are given in the relevant columns under the broad sub-heading at I and II of the statement.

(iv)

Ownership interest in the case of a partnership firm will be determined on the basis of profit sharing ratio of partners of the firm.