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)
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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:
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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
registered at Companies House under company number
dissolution.
(3) (“the company”)
(4) at the date of its
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.
2. 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.
3. Grounds for application [Please state why you consider a discretionary grant should
be made.]
4. 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.
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5. 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 that where the grant is over £750.00 a 5% reservation will be retained.
6. 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.
7. 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
this
day of
(9)
201
before me
(10)
Full Name:
Solicitor/Commissioner for Oaths
Please insert the following information:
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
full name(s)
full address(es)
company name
company number
charity registration number
Recipient charity
Recipient charity registration number
Full name of Payee
business name and address of Solicitor/Commissioner for Oaths
signature of Solicitor/Commissioner for Oaths
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