Statement of unpaid or unclaimed dividend and interest thereon transferred to general revenue account of the Central Government

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....[1][FORM No. I [See rule 4] The Companies Act, 1956   Registration No. .................                                                 &....

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....entitled to receive the amount No. of shares held Equity Preference 1 2 3 4 5 6               Particulars of dividends Amount due       Date of declaration                Date of transfer to Un-paid Dividend Account....