FORM – 1 Details of dissolution

utual Societies Application Form

Instrument of Dissolution of an Incorporated Friendly

Society

Form

1 / Details of dissolution

Society details

1.1 Society details

Register number

1.2 Date the dissolution of the society commences (dd/mm/yyyy)

/ / /

Assets and liabilities

1.3 Enter below the liabilities and assets of the society

Liabilities / £ / Assets / £
Total liabilities / Total assets

1.4 How will the creditors shown in question 1.3 be paid?

1.5 How will the remaining funds and property of the society be appropriated and divided after the payment of all debts and expenses?

Details of members

1.6 Number of members

1.7 What is the nature of the members' interest in the society?

Trustees

1.8 Names of people who are appointed as trustees for the purposes of the dissolution and the amount they will be remunerated

Full name
Address
Postcode
Remuneration / £
Full name
Address
Postcode
Remuneration / £
Full name
Address
Postcode
Remuneration / £
Full name
Address
Postcode
Remuneration / £

Please use separate sheets of paper if you need more space.

Please indicate how many separate sheets of paper you have used.

FCA l Mutuals Instrument of Dissolution FS92 (F) l Release 1 l April 2013 page 3

FORM – 2 Special resolution

2 / Special resolution
All applicants must complete this section.

2.1 How was the resolution passed?

At a general meeting

By a postal ballot

2.2 You must confirm the following:

·  At least 14 days’ notice (or any longer period that the society's rules require) was given, expiring with the final date for the receipt of instruments appointing proxies to vote at the meeting (or the date of meeting where proxy voting does not apply), or in the case of a postal ballot, expiring with the final date for the receipt of completed ballot papers.

·  The notice of the meeting (or in the case of a postal ballot, the ballot papers) included a statement that the resolution would not be effective unless it was passed as a special resolution

Confirmed

2.3 You must confirm how the resolution was approved

by at least three-quarters or more of those members of the society entitled to vote on it and voting either in person or by proxy at the meeting.

by at least three-quarters or more of the delegates entitled to vote on it and voting at the meeting.

by at least three-quarters or more of those members of the society entitled to vote on it and voting in a postal ballot.

2.4 Enter below the exact wording of the special resolution that was approved

Signatures

2.5 The Secretary of the society must sign below

Signature

2.6 The chairman of the meeting where the special resolution was passed must sign below

Signature

2.7 Date of application

Date / dd/mm/yy

FCA l Mutuals Instrument of Dissolution FS92 (F) l Release 1 l April 2013 page 3

FORM -3 Declaration

3 / Declaration
All applicants must complete this section.

Declaration

3.1 A trustee appointed by the society for the purposes of its dissolution must sign below in front of a solicitor, a commissioner for oaths, a notary public or a justice of the peace

I do solemnly and sincerely declare that in making the Instrument of Dissolution that all the relevant provisions of the Friendly Societies Act 1992 have been complied with.

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

Name
Signature
Date / dd/mm/yy

Declared before me:

a solicitor;

a commissioner for oaths;

a notary public; or

a justice of the peace.

Name
Declared at
Signature
Date / dd/mm/yy

FCA l Mutuals Instrument of Dissolution FS92 (F) l Release 1 l April 2013 page 3