THIRD SCHEDULEForm of Statement in lieu of Prospectus to be delivered to Registrar by a Private Company on becoming a Public Company and Reports to be set out therein

Part IForm of Statement and Particulars to be contained therein

The Companies Act, 1948 Statement in lieu of Prospectus delivered for registration by [Insert the name of the company.] Pursuant to section 30 of the Companies Act, 1948

Delivered for registration by
The nominal share capital of the company.£
Divided intoShares of £ each.
Shares of £ each.
Shares of £ each.
Amount (if any) of above capital which consists of redeemable preference shares.Shares of £ each.
The earliest date on which the company has power to redeem these shares.
Names, descriptions and addresses of directors or proposed directors.
Amount of shares issuedShares
Amount of commissions paid in connection therewith.
Amount of discount, if any, allowed on the issue of any shares, or so much thereof as has not been written off at the date of the statement.
Unless more than one year has elapsed since the date on which the Company was entitled to commence business :—
Amount of preliminary expenses By whom those expenses have been paid or are payable.£
Amount paid to any promoterName of promoter :—Amount £
Consideration for the paymentConsideration:—
Any other benefit given to any promoter.

Name of promoter :—

Nature and value of benefit:—

Consideration for giving of benefitConsideration:—
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 as fully or partly paid up otherwise than for cash or agreed to be so issued at the date of this statement.1. shares of £ fully paid.
2. shares upon which £ per share credited as paid.
Consideration for the issue of those shares or debentures.3. debenture £
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 (i) purchased or acquired by the company within the two years preceding the date of this statement or (2) agreed or proposed to be purchased or acquired by the company, except where the contract for its purchase or acquisition was entered into in the ordinary course of business and there is no connection between the contract and the company ceasing to be a private company or where the amount of the purchase money is not material.
Amount (in cash, shares or debentures) paid or payable to each separate vendor.
Amount paid or payable in cash, shares or debentures for any such property, specifying the amount 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.
Dates of, parties to, and general nature of every material contract (other than contracts entered into in the ordinary course of business or entered into more than two years before the delivery of this statement).
Time and place at which the contracts or copies thereof may be inspected 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 foreign language, a copy of a translation thereof in English or embodying a translation in English of the parts in a foreign language, as the case may be, being a translation certified in the prescribed manner to be a correct translation.
Names and addresses of the auditors of the company.
Full particulars of the nature and extent of the interest of every director in any property purchased or acquired by the company within the -two years preceding the date of this statement or proposed to be purchased or acquired by the company or, where the interest of such a director consists in being a partner in a firm, the nature and extent of the interest of the firm, with a statement of all sums paid or agreed to be paid to him or to the firm in cash or shares, or otherwise, by any person either to induce him to become or to qualify him as, a director, or otherwise for services rendered or to be rendered to the company by him or by the firm.
Rates of the dividends (if any) paid by the company in respect of each class of shares in the company in each of the five 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.

(Signatures of the persons above-named as directors or proposed directors or of their agents authorised in writing.) __________________________________ Date. _________________