FormNumber 22 FormSection 165 FormLaw Corporate FORM NO.

22
FormTitle Statutory Report
No. of Company x
Nominal Capital x
THE COMPANIES ACT, 1956
FormParentAct The Companies Act, 1956
Statutory Report
[Pursuant to section 165]
Name of Company xxx
Statutory Report of the xxx
Certified and filed pursuant to section 165 (5)
Date of Notice for holding statutory meeting x
Date of meeting x
[Place where meeting is to be held] x
Presented by xx

The Board of Directors submits this statutory report to the members in pursuance of section 165.

1. Shares allotted and cash received up to (a)

No. of Nominal value Cash received
shares of each share up to (a)
(a) Allotted subject to payment thereof in
cash
1 Equity x x x
2 Redeemable Preference Shares x x x
3 Preference shares other than x x x
Redeemable Preference Shares
(b) Allotted as fully paid-up otherwise than
in cash and the consideration for which
they have been allotted.
1 Equity x x x
2 Redeemable Preference Shares x x x
3 Preference shares other than x x x
Redeemable Preference Shares
(c) 6Allotted as partly paid-up to the extent
7of Rs. x 87per share, 9
and
10the consideration for which they 11
have been so allotted.
1 Equity x x x
2 Redeemable Preference Shares x x x
3 Preference shares other than x x x
Redeemable Preference Shares
2. Abstract of receipts and payments up to (a) x
 Receipts Rs. Payments Rs.

Shares x Preliminary expenses x

Equity x Commission on issue or sale x
of shares
Redeemable Preference Shares x Discount on issue or sale of x
shares
Preference shares other than x
Redeemable Preference Shares
Advance Payment for shares x Capital Expenditure
Debentures x
Loans x
Land x
Deposits x
Building x
Other Sources (to be specified) x
Plant x
Machinery x
Other items to be specified, x
balances
Cash In Hand x
Cash At Bank x
At post office x
Saving Bank x
Total x Total x
(a) The date should be within 7 days of the Report.

3 Preliminary expenses as estimated in the Prospectus or Statement in lieu of Prospectus Rs.

but actually incurred to the date are as under:

Preliminary Preliminary expenses

expenses actually estimated to be incurred
incurred up to after the aforesaid date.
aforesaid date Rs.
Rs.
Law Charges x x
Other charges in connection with the x x
preparation of the Memorandum and
Articles of Association.
Printing expenses x x
Registration charges x x
Advertisement charges x x
Commission on issue or sale of shares x x
Discount on issue or sale of shares x x
(other initial expenses. To be specified as x x
far as possible)

Total Rs. x x
4. Names, addresses and occupations of the company’s Directors, Auditors, Manager and
Secretary.

Name(s) Address(s) Occupation Particulars(s) of Date of

change(s) if any, in the
entries in columns change
(1),(2),(3) since the
date of incorporation
(1) (2) (3) (4) (5)
A. Directors
xx xx x x x
xx xx x x x
xx xx x x x
xx xx x x x
xx xx x x x
B. Auditors
xx xx x x x
xx xx x x x
C. Managing Agent / Secretaries and Treasurers

D. Manager

E. Secretary

These particulars must include dates of changes

5. Particulars of any contract which is to be

submitted to the statutory meeting for
approval. (If any modification or
proposed modification of a contract is to
be submitted for such approval brief
particulars of contract and particulars of
modification or proposed modification
should be given.)
6. Under-writing contracts. x x x
Brief description of each contract. If
contract not carried out fully, extent to
which it has not been carried out and
reasons therefore.

7. The arrears, if any, due on calls from

Directors and Managers.
 NAMES Amount
due
Directors : xx
Managers: xx
8. Particulars of any commission or brokerage paid or to be paid in connection with the issue
or sale of shares to any Director, or Manager thereof.

NAMES Commission or Brokerage paid or to be paid

On Shares On Debentures
Directors : x x
Manager x x

Dated this Day of x 200 x

We hereby certify that the given report is correct.

______________________________
Signature of two or more Directors.

We hereby certify as correct so much of the reports as relates to the shares allotted by the
company and to the cash received in respect of such shares and to the receipts and payments.

Signature of Auditors ________________

Dated this x Day of 200 x