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Form No. 4
( See Rule 37 )
Application by Depositor under sec. 50 (9)
Before the Company Law Board ( Western Region Bench )

In the matter of the Companies Act, 1956 (1 of 1956) Sect.58-A.


____________________________________
AND  
In the matter of (State the name of the Depositor-applicant.
____________________________________
AND  
In the matter of (State the name of the Company)
____________________________________
1. Name and Address of the depositor/Applicant ____________________________________
2. Name of the Company and address of its Registered Office ____________________________________
3. Name (s) of Depositor (s) with full address ____________________________________
4. Amount of Deposit ____________________________________
5. Fixed Deposit Receipt Number and Date (Photostate copy to be enclosed) ____________________________________
6. Terms and conditions of Deposit, as also date of maturity of deposit ____________________________________
7. Details of Payments made by the Company, if any ____________________________________
8. Actual amount due as on date of application (Principal/Interest) ____________________________________
9. Details of correspondence, if any, made between the Company and the Depositor (Copy of correspondence to be enclosed) ____________________________________
10. Any other particulars, as may be considered relevant. ____________________________________
  The Depositor- Applicant, therefore, prays :
a) That the company mentioned hereinabove, be directed to make repayment of the aforesaid deposit (s) alongwith interest due thereon, in accordance with the terms and conditions of the deposit).
b) That such further orders be passed, as the Company Law Board may deem fit in the circumstances of the case.
  Place: _____________________ _______________________________
  Date: _____________________ (Signature of Depositor/Applicant)
 
  Note:
a) The Application shall be accompanied by a Fee of Rs. 50/- (Rupees Fifty only) by way of a challan, evidencing remittance of cash into PNB under the Head of A/c. 1475-OGES-1, Fees realised by the Central Governme nt and Company Law Board on application made to it under Companies Act, 1956 OR By way of Bank Draft in favour of : 'The Pay & Accounts Officer, Department of Company Affairs, Calcutta/Delhi/Mumbai/Madras) as applicable.'
b) The Application and enclosures shall be made in DUPLICATE.
  DEMAND DRAFT OF RS. 50/- (RUPEES FIFTY ONLY)
(to be sent in cities in respective region) :
  Address of Four Regional Offices are as under:
  COMPANY LAW BOARD -
WESTERN REGION BENCH,
NTC House, 2nd Floor,
15, N.M. Marg, Ballard Estate,
MUMBAI - 400 038.
COMPANY LAW BOARD -
SOUTHERN REGION BENCH,
Block 8, 26 Haddows Road,
MADRAS - 600 006.
  COMPANY LAW BOARD -
EASTERN REGION BENCH,
9, Old Post Office Street,
6th Floor, CALCUTTA - 700 001.
COMPANY LAW BOARD -
PRINCIPAL BENCH, 5th Floor,
'A' Wing, Shastri Bhawan,
Dr. Rajendra Prasad Road,
NEW DELHI.
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