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7/23/2019 Form Fcgprblank

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Annex I[Annex to A. P. (DIR Series) Circular No. 44 dated May 30 !00"#

FC-GPR

PART – A

(To be filed by the company through its Authorised Dealer Category – I bank with the Regional Office of the RI under whose !urisdiction the Registered Office of the company making thedeclaration is situated as and when shares " con#ertible debentures are issued to the foreignin#estor$ along with the documents mentioned in item %o& ' of the undertaking enclosed to thisform

Per$anent Account Nu$%er (PAN) o& t'e inestee co$any*ien %y t'e Inco$e +ax

Deart$ent ,,,,,,,,,,,,,,

Date o& issue o& s'ares -

Conerti%le de%entures ,,,,,,,,,,,,,,

No Particulars (In loc/ etters)

1. Na$e

Address o& t'e Re*istered o&&ice

StateRe*istration No. 2ien %y Re*istrar o& Co$anies

'et'er existin* co$any or neCo$any

I& existin* co$any *ie re*istrationnu$%er allotted %y RI &or 5DI i& any

+ele'one

5axe6$ail

!. Descrition o& t'e $ain %usinessactiity

NIC Code

ocation o& t'e ro7ect and NIC code&or t'e district 'ere t'e ro7ect is



located

Percenta*e o& 5DI alloed as er 5DIolicy

State 'et'er 5DI is alloed under Auto$atic Route or aroal Route(stri/e out 'ic'eer is not alica%le)

3. Details o& t'e &orei*n inestor-colla%orator

Na$e

Address

Country

Constitution-Nature o& t'e inestin*

8ntity[Seci&y 'et'er

1. Indiidual!. Co$any3. 5II4. 59CI:. 5orei*n +rust;. Priate 8<uity 5und=. Pension-Proident 5und". Soerei*n ealt' 5und (S5>?. Partners'i-Prorietors'i 5ir$

10. 5inancial Institution11. NRI@s-PI1!. t'ers (lease seci&y)

Date o& incororation

_____________________

∗ I& t'ere is $ore t'an one &orei*n inestor-colla%orator searate Annex $ay %eincluded &or ite$s 3 and 4 o& t'e 5or$.BS5 $eans a 2oern$ent inest$ent e'icle 'ic' is &unded %y &orei*nexc'an*e assets and 'ic' $ana*es t'ose assets searately &ro$ t'e o&&icialreseres o& t'e $onetary aut'orities.

4. Particulars of Shares / Convertible Debentures Issue



a. !ature an ate of issue

!ature of Issue Date of Issue !u"ber of shares / convertibleebentures

01 IP-5P

0! Pre&erential allot$ent-Priatelace$ent

03 Ri*'ts

04 onus

0: Conersion o& 8C

0; Conersion o& royalty(includin* lu$ su$ay$ents)

0= Conersion a*ainst i$ort o&caital *oods %y units inS8

0" 8SPs

0? S'are Sa10 t'ers (lease seci&y)

8<uity s'ares

+otal

%) T#$e of securit# issue

!o% !ature ofsecurit#

!u"ber &aturit# Face'alue

Pre"iu" IssuePrice$er Share

A"ount(f inflo)

01 8<uity

0! Co$ulsorilyConerti%leDe%entures

03 Co$ulsorilyConerti%lePre&erence s'ares

04 t'ers (leaseseci&y)

+otal

i) In case t'e issue rice is *reater t'an t'e &ace alue lease *ie %rea/ u o& t'e re$iu$ receied.

ii) In case t'e issue is a*ainst conersion o& 8C or royalty or a*ainst i$ort o& caital *oods %y units in S8 a C'artered AccountantEs Certi&icate certi&yin* t'ea$ount outstandin* on t'e date o& conersion.

c rea/ u o& re$iu$ A$ount

Control Pre$iu$

Non co$etition &ee

t'ers

+otal

F please specify the nature



d Total inflo) (in Ruees) on account o&issue o& s'ares-conerti%le de%enturesto non6residents (includin* re$iu$ i&any) ide

i) Re$ittance t'rou*' ADGii) De%it to NR8-5CNR A-c it'an/ HHHHHHHHHHHHHHHHHHHH iii) t'ers (Please seci&y)

Date o& reortin* o& (i) and (ii) a%oeto RI under Para ? (1) A o& Noti&ication No. 58MA !0-!0006R

dated May 3 !000 as a$ended&ro$ ti$e to ti$e.

1. Re$ittance t'rou*' HHHHH %an/

e Disclosure of fair value of shares issue

e are a listed co$any and t'e$ar/et alue o& a s'are as on date o& t'e issue is

e are an un6listed co$any and t'e&air alue o& a s'are is

before issue of shares *(Please indicate as applicable)

*% Post issue $attern of shareholin+

,uit# Co"$ulsoril# convertible $referenceshares/Debentures

Inestor cate*ory

N o o &

s ' a r e s

A $ o u n t

( 5 a c e 9 a l u e )

R s .

I

N o o & s ' a r e s

A $ o u n t

( 5 a c e 9 a l u e )

R s .

I

a) Non J Resident

01 Indiiduals

0! Co$anies

03 5IIs

04 59CIs



0: 5orei*n+rusts

0; Priate8<uity 5unds

0= Pension-Proident5unds

0" Soerei*nealt' 5unds

0? Partners'i-Prorietors'i

5ir$s

10 5inancialInstitutions

11 NRIs-PI

1! t'ers(Pleaseseci&y)

Su% +otal

% Resident

+otal



D,C.ARATI(! T( , FI.,D 0 T1, A2T1(RIS,D R,PR,S,!TATI', (F T1,I!DIA! C(&PA!03 (Delete whichever is not applicable and authenticate)

e 'ere%y declare t'atG

1. e co$ly it' t'e rocedure &or issue o& s'ares - conerti%le de%entures as laiddon under t'e 5DI sc'e$e as indicated in Noti&ication No. 58MA !0-!0006R dated3rd May !000 as a$ended &ro$ ti$e to ti$e.

!. +'e inest$ent is it'in t'e sectoral ca-statutory ceilin* er$issi%le under t'e Auto$atic Route o& RI and e &ul&ill all t'e conditions laid don &or inest$ents under t'e Auto$atic Route na$ely (stri/e o&& 'ic'eer is not alica%le).

a) 5orei*n entity-entitiesK(ot'er t'an indiiduals) to 'o$ e 'ae issueds'ares 'ae existin* 7oint enture or tec'nolo*y trans&er or trade $ar/

a*ree$ent in India in t'e sa$e &ield and Conditions stiulated in Press Note 1 o& !00: Series dated Lanuary 1! !00: 'ae %een co$lied it'.

(R5orei*n entity-entitiesK(ot'er t'an indiiduals) to 'o$ e 'ae issued s'aresdo not 'ae any existin* 7oint enture or tec'nolo*y trans&er or trade $ar/a*ree$ent in India in t'e sa$e &ield.

%) e are not an SSI unit.

(R

e are a SSI nit and t'e inest$ent li$it o& !4 o& aid Ju caital 'as %eeno%sered - re<uisite aroals 'ae %een o%tained

c) S'ares issued on ri*'ts %asis to non6residents are in con&or$ity it'Re*ulation ; o& t'e RI Noti&ication No 58MA !0-!0006R dated 3 rd May !000as a$ended &ro$ ti$e to ti$e.

(RS'ares issued are %onus s'ares.

(R

S'ares 'ae %een issued under a sc'e$e o& $er*er and a$al*a$ation o& to or $ore Indian co$anies or reconstruction %y ay o& de6$er*er or ot'erise o& anIndian co$any duly aroed %y a court in India.

(R

S'ares are issued under 8SP and t'e conditions re*ardin* t'is issue 'ae%een satis&ied.



3. S'ares 'ae %een issued in ter$s o& SIA-5IP aroalNo.HHHHHHHHHHHHHHHHHHH dated HHHHHHHHHHHHHHHHHHHH N-A

4. e enclose t'e &olloin* docu$ents in co$liance it' Para*ra' ? (1) () o& Sc'edule 1 to Noti&ication No. 58MA !0-!0006R dated May 3 !000G

(i) A certi&icate &ro$ our Co$any Secretary certi&yin* t'at

(a) all t'e re<uire$ents o& t'e Co$anies Act 1?:; 'ae %een co$lied it'

(%) ter$s and conditions o& t'e 2oern$ent aroal i& any 'ae %een co$liedit'

(c) t'e co$any is eli*i%le to issue s'ares under t'ese Re*ulations and

(d) t'e co$any 'as all ori*inal certi&icates issued %y aut'oriOed dealers in Indiaeidencin* receit o& a$ount o& consideration in accordance it' ara*ra' " o&

Sc'edule 1 to Noti&ication No. 58MA !0-!0006R dated May 3 !000.

(ii) A certi&icate &ro$ Statutory Auditors - C'artered Accountant indicatin* t'e $anner o&arriin* at t'e rice o& t'e s'ares issued to t'e ersons resident outside India.

:. ni<ue Identi&ication Nu$%ers *ien &or all t'e re$ittances receied as consideration&or issue o& s'ares-conerti%le de%entures (details as a%oe) %y Resere an/.

,,,,,,,,,,,,,,

,,,,,,,,,,,,,,

(Si*nature o& t'e Alicant) GHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH (Na$e in loc/ etters) GHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH (Desi*nation o& t'e si*natory) GHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH

PlaceG

DateG

( +o %e si*ned %y Mana*in* Director-Director-Secretary o& t'e Co$any)



C,RTIFICAT, T( , FI.,D 0 T1, C(&PA!0 S,CR,TAR04 (F T1, I!DIA!C(&PA!0 ACC,PTI!G T1, I!',ST&,!T3

(As per Para 9 (1) (B) (i) of Schedule 1 to Notification No !"#A $%&$%%%'B dated #ay $%%%)

In resect o& t'e a%oe$entioned details e certi&y t'e &olloin*G

1. All t'e re<uire$ents o& t'e Co$anies Act 1?:; 'ae %een co$lied it'.

!. +er$s and conditions o& t'e 2oern$ent aroal i& any 'ae %een co$lied it'.

3. +'e co$any is eli*i%le to issue s'ares - conerti%le de%entures under t'eseRe*ulations.

4. +'e co$any 'as all ori*inal certi&icates issued %y AD Cate*ory J I %an/s in Indiaeidencin* receit o& a$ount o& consideration in accordance it' ara*ra' " o&

Sc'edule 1 to Noti&ication No. 58MA !0-!0006R dated May 3 !000.

(Na$e Si*nature o& t'e Co$any Secretary) (Seal)

F(R 2S, (F T1, R,S,R', A!5 (!.03

Re+istration !u"ber for the FC-GPR3 ,,,,,,,,,,,,,,

2niue Ientification !u"ber allotte to theCo"$an# at the ti"e of re$ortin+ recei$t of

Re"ittance ,,,,,,,,,,,,,,

Q I& t'e co$any doesn@t 'ae a &ull ti$e Co$any Secretary a certi&icate &ro$ aractisin* Co$any Secretary $ay %e su%$itted.

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