Please ensure this form is placed at the top of your application, if posted to
Companies House, and the Company Name is consistent throughout all
documents
CIC 36
Declarations on Formation of a
Community Interest Company1
Please The Village Shop
complete in Company Name in full
typescript,
or in bold
black
capitals.
Community Interest Company
SECTION A: COMMUNITY INTEREST STATEMENT – beneficiaries
1. We/I, the undersigned, declare that the company will carry on its
activities for the benefit of the community, or a section of the
community2. [Insert a short description of the community, or section of
the community, which it is intended that the company will benefit below
]3
The company’s activities will provide benefit to ...
In particular, the company’s activities will be carried on for the
benefit of residents of The Village and small-scale producers of food and
beverages in the surrounding area.
COMPANY NAME The Village Shop Community Interest Company
SECTION B: Community Interest Statement – Activities & Related Benefit
Please indicate how it is proposed that the company’s activities will benefit the community, or
a section of the community. Please provide as much detail as possible to enable the CIC
Regulator to make an informed decision about whether your proposed company is eligible to
become a community interest company. It would be useful if you were to explain how you
think your company will be different from a commercial company providing similar services or
products for individual or personal gain.
Activities How will the activity benefit the community?
(Tell us here what the company (The community will benefit by…)
is being set up to do)
General: running a village The Village currently has no shop, but it has a substantial
shop with a strong population, who would benefit from access to a local grocer
community focus and and general store (particularly the elderly and those without
providing services to local cars). The company will provide a number of new full-time
residents and holidaymakers and part-time jobs, enhance the opportunities for local food
producers and help to strengthen community spirit.
Retailing locally produced The shop will provide a distribution channel for locally based
food (including eggs, producers who operate on too small a scale to supply larger
vegetables, fruit, cakes, pies, wholesalers and retailers. We hope that the availability of
bread and preserves) and local produce will be a selling point for both local residents
beverages. Home delivery and tourists. Local distribution will also help to reduce “food
(telephone orders) to local miles”. We would also like to establish links with other
residents, especially the networks of smallscale producers and retailers to develop
elderly and others with ways of improving local and small-scale food distribution
impaired mobility networks. The Village has no shop and is not well served by
public transport. The nearest supermarket is at least 20
minutes away by car.
If the company makes any surplus it will be used for…
We hope to generate a surplus from trading. We expect that this will all be reinvested in the
business.
(Please continue on separate sheet if necessary.)
Version 5 - Last Updated on 04/04/2019
COMPANY NAME The Village Shop Community Interest Company
SECTION C:
1. We/I, the undersigned, declare that the company in respect of which this application is
made will not be:
(a) a political party;
(b) a political campaigning organisation; or
(c) a subsidiary of a political party or of a political campaigning organisation.4
SECTION D:
If this section is not completed your application will be rejected.
TYPED NAMES ARE NOT ACCEPTABLE AND WILL BE REJECTED
Each person
who will be a Signed Date 08/04/2019
first director of
the company Signed Date 08/04/2019
must sign the
declarations. Signed Date 08/04/2019
Signed Date
[Signed or
scanned
Signed Date
signatures
are allowed.] Signed Date
Signed Date
Signed Date
Signed Date
Signed Date
You do not have to give any contact
information in the box opposite but
if you do, it will help the Registrar of
Companies to contact you if there is
a query on the form. The contact
information that you give will be Tel
Version 5 - Last Updated on 04/04/2019
visible to searchers of the public DX Number DX Exchange
record.
Version 5 - Last Updated on 04/04/2019
CHECKLIST
ALL Applications
• Have the first directors signed the CIC36? (typed names instead of signatures are not
accepted)
• Is the company name consistent throughout?
Hardcopy Applications only
This form must be posted with the following documents:
(a) Memorandum of Association
(b) Articles of Association, which comply with CIC legislative requirements
(c) Form IN01- indicating that the proposed company is adopting bespoke articles.
(d) Any completed continuation sheets
(e) A cheque or postal order for £35 made payable to Companies House
When you have completed and signed this form, please ensure it is placed at the top of your
application and send it to the Registrar of Companies at:
For companies registered in England and Wales:
New Companies Section, Companies House, Crown Way, Cardiff, CF14 3UZ
DX 33050 Cardiff
For companies registered in Scotland:
Companies House, 4th Floor, Edinburgh Quay 2, 139 Fountainbridge, EH3 9FF
DX 235 Edinburgh
For companies registered in Northern Ireland:
Companies House, 2nd Floor, The Linenhall, 32-38 Linenhall Street, Belfast, BT2 8BG
NOTES
1
This form will be placed on the public record. Any information relevant to the application that you do not
wish to appear on the public record, should be described in a separate letter addressed to the CIC Regulator
and delivered to the Registrar of Companies with the other documents.
2
The community interest test is referred to in section 35 of the Companies (Audit, Investigations and
Community Enterprise) Act 2004 and is expanded upon in regulations 3, 4 & 5 of the Regulations.
3
E.g. “the residents of Oldtown” or “those suffering from XYZ disease”.
4
A company is not eligible to be formed as a community interest company if it will be an “excluded
company”. If you are not sure whether the company which you wish to form falls into any of these
categories, you should refer to the definitions of the terms “political party”, “political campaigning
organisation” and “subsidiary” (and of the related terms “election”, “governmental authority”, “public
authority” and “referendum”) in Regulation 2 of the Regulations before completing this form.
Version 5 - Last Updated on 04/04/2019
