Return of Allotments Which Have Become Void

Form CM 16 REPUBLIC OF NAMIBIA COMPANIES ACT 2004 (Section 99(4)) (Regulation 26(2)) RETURN OF ALLOTMENTS WHICH HAVE BECOME VOID

Registration Number of Company Revenue stamp or revenue franking machine impression N$10,00

Name of Company 1. Authorised capital of company:

NO PAR VALUE PAR VALUE Nominal amount of Authorised number of Authorised capital Class of shares Number of shares Class of Shares each share shares N$ N$

Total

2. Issued capital of company as shown on the return of allotments dated ______

NO PAR VALUE PAR VALUE Number Class of shares Issue price Stated Number Class of shares Nominal Premium Total Total amount of of shares per share capital of shares amount of on each premium paid-up capital, each share share account excluding premium account N$ N$ N$ N$ N$ N$

Total

Summary of total issued capital as shown on the return of allotments : Amount of Issue Paid-up capital N$ ………………………………………… Stated Capital N$ ……………………………………………………………... Premium account …………………………………………………………. N$ Total issued capital N$ ………………………………………………………..

Continuation of Form CM 16 3. Particulars of allotment which has become void NO PAR VALUE PAR VALUE Number Class of shares Issue price Stated Number Class of shares Nominal Premium Total Total capital of shares per share capital of shares amount of on each premium excluding each share share account premium N$ N$ N$ N$ N$ N$

Total 4. Reasons for allotment becoming void

5. Issued capital of company at date of this return NO PAR VALUE PAR VALUE Number Class of shares Issue price Stated Number Class of shares Nominal Premium Total Total amount of of shares per share capital of shares amount of on each premium paid-up capital, each share share account excluding N$ N$ premium account N$ N$ N$ N$

Total Summary of total issued capital as shown on the return of allotments : Amount of Issued Paid-up capital N$ Stated Capital N$ Premium account N$ Total issued capital N$ Certified correct Date ______Signature ______Director/Manager/Secretary

Rubber stamp of company, if any, or of secretaries

Perforated (To be completed by the Company)

Acknowledgement of receipt of return of allotments having become void, Date of receipt by Registrar of dated Companies ______

Name of Company

Registrar of Companies

Postal Address Date stamp of Companies Registration Office