DG3

APPLICATION FORM FOR DISCRETIONARY GRANT

COMPANY CANNOT BE RESTORED (CB3)

Please read the CB3 Guidelines on discretionary grants before completing this application form and the Statutory Declaration. Please note that any grants we may make and the terms upon which grants are made are entirely discretionary.

This form consists of two parts:

Application Form

And

Statutory Declaration

You must complete both parts.

APPLICATION FORM

(A) PERSONAL DETAILS

Full Name:______

Address:______

If you have instructed a solicitor or any other professional in relation to this application, please provide their details:

Name:______

Address:______

Reference:______

(B) DISSOLVED COMPANY/CHARITY/NON-PROFIT ORGANISATION

Company/Charity Name/Non-Profit Organisation:______

Company Number:______

Registered Charity Number (if applicable)______

Last Registered Office Address:______

Date of Incorporation:______

Date Dissolved:______

Your status: [Former Shareholder] [Former Liquidator] [Former administrator] [Former company voluntary arrangement supervisor] (please delete as appropriate) [Other]______(please state)

Bank/Building Society Details of Dissolved Company:

Bank Name and Address:______

Account Number: ______

Sort Code:______

Amount in Account:______

Details of any other assets:______

If this application is regarding assets other than cash in bank/building society accounts, please use the space provided below to briefly tell us what evidence you are submitting of the company’s ownership of those other assets prior to dissolution:

(C) NATURE OF YOUR APPLICATION

Amount applied for:______

Reason for application:

(D) STATUTORY DECLARATION

[ ] Please tick box to confirm that you have completed the Statutory Declaration below and attached it to this application form and signed and dated it in the presence of a practising solicitor or commissioner for oaths.

(E) CHECKLIST

Please complete the following checklist before you sign and date Section F (Declaration) of this form.

[ ] I confirm that the company cannot be administratively restored to the Companies Register.

[ ] I have provided all the relevant information, including (where appropriate) evidence of ownership of non-cash assets prior to dissolution.

[ ] I have provided an office copy of the grant of Probate or Letters of Administration in respect of any deceased shareholder (if appropriate).

[ ] I have completed, signed and dated the relevant Statutory Declaration.

[ ] I have submitted 2 forms of identity in line with CB3 Guidelines. Any copies I have submitted have been certified.

(F) DECLARATION

I confirm that all the information I have given in this application form and the Statutory Declaration is correct to the best of my knowledge.

Signature:

Full name:

Date:

STATUTORY DECLARATION

COMPANY CANNOT BE RESTORED (CB3)

I/we (1) of (2)

DO SOLEMNLY AND SINCERELY DECLARE as follows:-

  1. Status (complete a b or c)

(a) I was/we were the only member/s of (3) (“the company”) registered at Companies House under company number (4) at the date of its dissolution.

OR

(b) I am/we are the Executor/s/Administrator/s of the estate of the deceased shareholder/s who was/were the only member/s of (3) (“the company”) registered at Companies House under company number (4) at the date of its dissolution.

OR

(c) I was/we were the liquidator/joint liquidators/administrator/joint administrators/company voluntary arrangement supervisor/s of (3) (“the company”) registered at Companies House under company number (4) at the date of its dissolution.

  1. Creditors (complete a, b or c)

(a). There were no outstanding creditors of the company at the date of its dissolution.

OR

(b). All outstanding creditors of the company at the date of its dissolution have since been paid in full.

OR

(c). I was/we were the last appointed insolvency practitioner/s dealing with the company’s affairs.Any grant will be distributed as if I/we were still the liquidator/joint liquidators/administrator/joint administrators/company voluntary arrangement supervisor/s of the company.

  1. Grounds for application [Please state why you consider a discretionary grant should be made.]
  1. No further relevant information or evidence

I/we confirm that I have set out all relevant facts and information in support of my application in paragraph 3 above.

  1. Treasury Solicitors costs and reservation

I/we acknowledge that the Treasury Solicitor’s proper legal costs and disbursements will be deducted from any grant and thatwhere the grant is over £750.00 a 5% reservation will be retained.

  1. Charities only (do not complete unless the dissolved company was a charity)

(a)The company was a charity registered under number (5).

(b)I/we can confirm that any grant made by the Treasury Solicitor will be paid to (6) (the “Intended Recipient”). The Intended Recipient is a charity registered under registration number (7).

(c) I/we confirm that the constitutions of both the Intended Recipient and the company permit the discretionary grant to be paid to the Intended Recipient.

(d) I/we confirm that the Charity Commission for England and Wales have no objections to the discretionary grant being paid to the Intended Recipient.

  1. Payment

I/we would like the cheque to be made payable to (8)

I/we make this solemn declaration conscientiously believing the same to be true and by virtue of the Statutory Declarations Act 1835.

Signed:

Full Name:

Declared at (9)

this day of 201

before me (10)

Full Name:

Solicitor/Commissioner for Oaths

Please insert the following information:

(1)full name(s)

(2)full address(es)

(3)company name

(4)company number

(5)charity registration number

(6)Recipient charity

(7)Recipient charity registration number

(8)Full name of Payee

(9)business name and address of Solicitor/Commissioner for Oaths

(10)signature of Solicitor/Commissioner for Oaths

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