PAS-5, record of private placement offers

Form PAS-5 — record of a private placement offer to be kept by the company

1. Name of the Company: [Company Name] Private Limited | CIN: [Company's CIN]
2. Address of the registered office: [Company's registered office address]
3. Date of the Board resolution authorising the offer: [Date of the board resolution authorising the offer]
4. Date of the special resolution of the Members: [Date of the special resolution of members]
5. Kind of security offered: [Equity shares / CCPS / CCD] of the face value of Rs [Face value of each equity share (Rs)] each
6. Price per security, including premium: Rs [Issue price per security (Rs)] | Total amount of the offer: Rs [Total amount to be raised (Rs)]
7. Number of identified persons to whom the offer is made: [Total number of identified persons] | of which QIBs [Number of QIBs among them] and ESOP employees under s.62(1)(b) [Number of ESOP employees among them]
8. Date of recording the names of the identified persons: [Date the identified persons' names were recorded]
9. Date of circulation of the offer letter in Form PAS-4: [Date of circulation of the PAS-4 offer letter]
10. Separate bank account: Account no. [Subscription account number] with [Bank and Branch], opened on [Date the separate bank account was opened]
11. Cumulative number of persons to whom offers of this kind of security have been made in the financial year [____-____], excluding QIBs and ESOP employees: [Persons offered this kind of security this year] of the ceiling of 200

12. Particulars of the identified persons to whom the offer is made