“Form No. BEN-1”
Declaration by the beneficial owner who holds or acquires significant beneficial ownership in shares
[Pursuant
to section 90(1) of the Companies Act, 2013 and rule 2A, 3]
To,
Name of the
company:
Registered
office address:
1. Purpose
of filing the form (choose any one)
For declaration of Significant Beneficial
Ownership under Section 90 For Change in Significant Beneficial
Ownership under Section 90
ID
of the Significant Beneficial Owner
2. Particulars
of the holder of the significant beneficial
interest:
|
Name of
the Significant Beneficial Owner (Given name and last Name)
|
|
|
Address
and Email id
|
|
|
Date of
Birth/Age
|
|
|
Father’s/
Mother’s/Spouse’s name
|
|
|
Occupation
|
|
|
Nationality
|
|
|
Passport
No. (in case of foreign national)
|
|
3A. Nature of indirect holding or exercise of
right in the reporting company through member of the reporting company (where more than one repeat
this para of the Form)
(a) Type of Member (Company/ LLP/Any other Body
Corporate/HUF/ Partnership Firm/Discretionary Trust/Charitable trust/Specific
Trust/Revocable Trust /Pooled Investment vehicle (PIV) / Entity controlled by
PIV)
(b) Corporate Identity number(CIN) or Limited
Liability Partnership Identification number(LLPIN) or any other registration
number allotted by the regulator established under the Act
|
(c) Name of the
Member
(d) Address
Line
I Line II
City
State
Country
Pin Code
(e) Nature of indirect holding or exercise of right
in the reporting company:
 |
o
By virtue of shares
%
o
By virtue of voting rights in shares %
By virtue of voting rights in shares %
o
By
virtue of rights on distributable dividend or any other distribution %
By
virtue of rights on distributable dividend or any other distribution %
o
By virtue of
exercise of control (attach copy of agreement)
o
By virtue of
exercise of significant influence (attach copy of agreement)
(f) Status
of significant beneficial owner in the member of the reporting company (choose
any one)
o
Individual
in case of company or any other body corporate
o
Partner in
case of partnership firm or LLP
o
Karta in
case of HUF
o
Trustee in
case of a discretionary trust or charitable trust
o
Beneficiary
in case of a specific trust
o
Author or
settler in case of a revocable trust
o
General
Partner, Investment Manager or CEO in case of pooled investment vehicle or
entity controlled by pooled investment
vehicle
(g) In case the member is a partnership firm or LLP, specify whether
significant beneficial owner:
o
is a partner
o
holds
majority stake in the body corporate partner
o
holds
majority stake in the ultimate holding company of the body corporate partner
(h) In case the member is a company or any other
body corporate, specify whether significant beneficial owner holds:
o
majority
stake in such company or body corporate
o
majority
stake in the ultimate holding company of such company or body corporate
(i) Whether Significant Beneficial Owner has any direct
holding or right
in the reporting company
Yes 
No
If yes,
enter details below:
By virtue
of shares %
By virtue of
voting rights in shares %
By
virtue of rights on distributable dividend or any other distribution %
By virtue of
exercise of control (attach copy of agreement)
By virtue of
exercise of significant influence (attach copy of agreement)
By virtue of
exercise of control (attach copy of agreement)
Date:
Place:
Signature of the holder of the significant
beneficial interest
*Attachments:
Attachments:
* (a) Proof of identity of the
registered owner and holder of the significant beneficial interest
(b)
Instrument/ document under which the significant beneficial interest is
created/ transferred/changed
Source: Companies (Significant Beneficial
Ownership) Amendment Rules, 2019
(http://www.mca.gov.in/Ministry/pdf/CompaniesOwnersAmendmentRules_08020219.pdf
)
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