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: Swiclub@yahoo.co.uk Telephone No:07513364838

Please provide correspondence name and address if different from above N/A

(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