Form D

DECLARATION TO BE FILED FOR NETWORK WITH ENTITIES OUTSIDE INDIA NETWORK WITH ENTITIES OUTSIDE INDIA REGISTRATION NO.

THE INSTITUTE OF CHARTERED ACCOUNTANTS OF INDIA PARTICULARS OF NETWORK WITH ENTITTIES OUTSIDE INDIA 1. Name of the Network 2. Address of the Network 3. Name(s) & address(es) of firm(s)/entity(ies) constituting the Network (A) Indian firm(s) forming part of Network: Name(s) of Firm(s) Firm Registration Number(s)

(B) Outside entity(ies) forming part of Network : (i) (ii) (iii) (iv) Name of the Network outside India The country where the entity is registered Nos. of member firms of such Network Date of registration of such entity

4. Date on which the Indian firm(s) have joined the Present Network arrangement 5. I/We, the authorized representative(s) of Indian Firm(s), solemnly declare and affirm that the information provided is true and fair to my/our knowledge and belief. I/We shall comply with the applicable rules of Networking. Copy of the authorization letter is enclosed herewith.

Place : Date :

Name(s) with Membership No(s) and signature(s) of duly authorized representative(s) of the Indian firm(s)/ Member constituting the Network