Ra15_repaying_funds_to_restored_companies.docx

RA15 APPLICATION FORM FOR REPAYING FUNDS TO RESTORED COMPANIES (CB4) Note: Please read theCB4guidelines on repaying funds to restored companies before completing this application form and the Payment Authority if applicable.

(A) PERSONAL DETAILS OF APPLICANT Full Name: Varsha Sabharwal Residential Address: 118 Hinton Avenue, Hounslow, TW46AP Email: [email protected] Telephone No:07513364838 Please provide correspondence name and address if different from above

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(B) DISSOLVED COMPANY /CHARITY/NON-PROFIT ORGANISATION Name of Company/Charity/Non-Profit Organisation: Goldpine Estates Limited Company Number: 03611720 Registered Charity Number (if applicable):_N/A_______ Registered Office Address: 118 Hinton Avenue, Hounslow, TW46AP Date Dissolved: 22/01/2019 Date Restored: 06/03/2019 Method of Restoration: Administrative Restoration (please state and enclose copy of the court order confirming court restoration or letter from Companies House confirming administrative restoration, whichever is applicable): attached Your status: Director

(C) NATURE OF YOUR APPLICATION Approximate balance of funds at date of dissolution: £ 5,900 Name of organisation(s) that transferred the funds:_Lloyds Bank Payment should be made payableto: March and Bloom Law Limited If payment is to be made payable to a third party other than the restored company please refer to section D on page 2

(D) PAYMENT AUTHORITY 1

[✓ ] Please tick box to confirm that the majority of the officers of the company have completed, signed and dated the Payment Authority attached to this application form. [✓ ] Please tick box to confirm you have submitted 1 proof of name and 1 proof of address document for each person signing the Payment Authority. ALL COPIES OF IDENTITY EVIDENCE MUST BE CERTIFIED BY A PRACTISING SOLICITOR OR THE POST OFFICE IDENTITY CHECKING SERVICE. (E) CHECKLIST Please complete the following checklist before you sign and date Section F (Declaration) of this form. [✓] I have provided all the relevant information. [✓] The majority of the officers of the company have completed, signed and dated the Payment Authority (if applicable). [✓] I have provided a copy of the court order restoring the company or confirmation from Companies House for administrative restoration as applicable. [✓] If a Payment Authority is being submitted, I confirm that I have enclosed 2 forms of identity for all those signing it and any copies have been certified. (F) DECLARATION I confirm that all the information I have given in this application form and the Payment Authority (if applicable) is correct to the best of my knowledge.

Signature: Full name: Varsha Sabharwal Date: 10/03/19

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