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This template for the waiver of a dividend by an individual is also available for editing as a Word document.

[Home address]

The Company Secretary,
[Company name]
[Registered office address]

I, [name] of [address] being the registered holder of [number] of [class of shares e.g. Ordinary] Shares of [par value e.g. £1.00] each fully paid in the capital of [company name] Limited, do hereby irrevocably waive for myself, my successors and assigns all right and entitlement to payment of the [interim or final] dividend of £[amount] per share declared by the company on [date declared] in respect of the year ended [year end date].

Signed and sealed this [number] day of [month and year] by the said [person signing]

[Signature]

in the presence of

[Signature]_______________________
Signature

________________________________
Witness name

________________________________
Witness address
________________________________

________________________________

________________________________

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