[persuant to section 130, 135, 137 & 138]
Registration No. Nominal Capital
Particulars of
charge(s)

created by a company
registered in India
Subject to which property
has been acquired by
company registered in
India

Name of the Company ………………………. Limited/Private Ltd.
Presented by……………
created

Particulars of
charges(s)

subject to which property
has been acquired …………………………………
Limited/Private Limited a company
registered in India.
PARTICULARS OF CHARGE UNDER SECTION 125
1. Date and description of the
instrument the creating the
charge.
2. Amount secured by the
charge/amount owing on
security of the charge
3. Short particulars of the property
charged. If the property
acquired is subject to charge,
date of the acquisition of
property should be given .
4. Gist of the terms and conditions
and extent and operation of the
charge.
5. Names and addresses and
description of the person
entitled to the charge.
PARTICULARS REGARDING
CREATION OF CHARGE IN CASE

OF SHRIES OF DEBENTURES
UNDER SECTION 128/129.
6. Date and amount of each series
of debentures —
Date Amount
Total
7. Date and amount of the present
issue of series.
8. Date of resolution authorising
the issue of series.
9. Date of the covering deed (if
any), by which the security is
created of defined; or if there is
no such deed, the first
execution of any debenture of
the series.
10. Names and addresses of the
trustee (if any) for the debenture
holder.
11. Date of registration of the
series.
12. Particulars as to the amount or
rate per cent of the commission,
allowances or discount (if any)
paid, or made either directly or
indirectly by the company to any
person in consideration of
subscribing or agreeing to
subscribe, whether absolutely of
conditionally or procuring or
agreeing to procure
subscription, whether absolute
or conditional, for any of the
debentures included in this
return.
PARTICULARS OF MODIFICATION OF
CHARGE UNDER SECTION 135.
13. Date and brief description of
instrument modifying the charge
14. Particulars of modifications
already registered/filed in the
office of the Registrar of
Companies.
15. Particulars of modification
specification specifying the
terms, conditions or the extent

of operation of the charge in
which modification is made, and
the details of the modification.
16. APPOINTMENT OF RECEIVER
UNDER SECTION 137.
a)Name, address and date of
appointment of receiver.
b)Date on which the receiver
ceased to act.
17. MEMORANDUM OF
COMPLETE SATISFACTION
OF CHARGE UNDER
SECTION 138.
a)Date of creation of original
charge and amount secured.
b)Date of registration/date of
filling of the particulars with
the Registrar of Companies:
c)Date of filing of the
memorandum of
satisfaction/Date of entry of
satisfaction.

Signature
Name
(in Block Capitals)
Designation

Dated this day of 19.

(FOR OFFICE OF REGISTAR OF COMPANIES ONLY)

18. Date of Registration.
19. Serial No. of the document in file.

Signature of Registrar of the Companies