diff --git a/src/routes/safe/components/Settings/ManageOwners/ReplaceOwnerModal/screens/OwnerForm/index.jsx b/src/routes/safe/components/Settings/ManageOwners/ReplaceOwnerModal/screens/OwnerForm/index.jsx
new file mode 100644
index 00000000..beefc586
--- /dev/null
+++ b/src/routes/safe/components/Settings/ManageOwners/ReplaceOwnerModal/screens/OwnerForm/index.jsx
@@ -0,0 +1,160 @@
+// @flow
+import React from 'react'
+import classNames from 'classnames/bind'
+import { withStyles } from '@material-ui/core/styles'
+import Close from '@material-ui/icons/Close'
+import IconButton from '@material-ui/core/IconButton'
+import Paragraph from '~/components/layout/Paragraph'
+import Row from '~/components/layout/Row'
+import GnoForm from '~/components/forms/GnoForm'
+import Col from '~/components/layout/Col'
+import Button from '~/components/layout/Button'
+import Block from '~/components/layout/Block'
+import Hairline from '~/components/layout/Hairline'
+import Field from '~/components/forms/Field'
+import TextField from '~/components/forms/TextField'
+import Identicon from '~/components/Identicon'
+import Link from '~/components/layout/Link'
+import OpenInNew from '@material-ui/icons/OpenInNew'
+import { getEtherScanLink } from '~/logic/wallets/getWeb3'
+import {
+  composeValidators,
+  required,
+  mustBeEthereumAddress,
+  minMaxLength,
+} from '~/components/forms/validator'
+import { styles } from './style'
+import { secondary } from '~/theme/variables'
+
+const openIconStyle = {
+  height: '16px',
+  color: secondary,
+}
+
+type Props = {
+  onClose: () => void,
+  classes: Object,
+  ownerAddress: string,
+  ownerName: string,
+  network: string,
+  onSubmit: Function,
+}
+
+const OwnerForm = ({
+  classes,
+  onClose,
+  ownerAddress,
+  ownerName,
+  network,
+  onSubmit,
+}: Props) => {
+  const handleSubmit = (values) => {
+    onSubmit(values)
+  }
+
+  return (
+    <React.Fragment>
+      <Row align="center" grow className={classes.heading}>
+        <Paragraph weight="bolder" className={classes.manage} noMargin>
+          Replace owner
+        </Paragraph>
+        <Paragraph className={classes.annotation}>1 of 2</Paragraph>
+        <IconButton onClick={onClose} disableRipple>
+          <Close className={classes.closeIcon} />
+        </IconButton>
+      </Row>
+      <Hairline />
+      <GnoForm onSubmit={handleSubmit}>
+        {(...args) => {
+          const formState = args[2]
+
+          return (
+            <React.Fragment>
+              <Block className={classes.formContainer}>
+                <Row noMargin>
+                  <Paragraph>
+                    Review the owner you want to replace from the active Safe. Then specify the new owner you want to replace it with:
+                  </Paragraph>
+                </Row>
+                <Row noMargin>
+                  <Paragraph>
+                    Current owner
+                  </Paragraph>
+                </Row>
+                <Row className={classes.owner}>
+                  <Col xs={1} align="center">
+                    <Identicon address={ownerAddress} diameter={32} />
+                  </Col>
+                  <Col xs={7}>
+                    <Block className={classNames(classes.name, classes.userName)}>
+                      <Paragraph size="lg" noMargin weight="bolder">
+                        {ownerName}
+                      </Paragraph>
+                      <Block align="center" className={classes.user}>
+                        <Paragraph size="md" color="disabled" noMargin>
+                          {ownerAddress}
+                        </Paragraph>
+                        <Link className={classes.open} to={getEtherScanLink(ownerAddress, network)} target="_blank">
+                          <OpenInNew style={openIconStyle} />
+                        </Link>
+                      </Block>
+                    </Block>
+                  </Col>
+                </Row>
+                <Row noMargin>
+                  <Paragraph>
+                    New owner
+                  </Paragraph>
+                </Row>
+                <Row margin="md">
+                  <Col xs={8}>
+                    <Field
+                      name="ownerName"
+                      component={TextField}
+                      type="text"
+                      validate={composeValidators(required, minMaxLength(1,50))}
+                      placeholder="Owner name*"
+                      text="Owner name*"
+                      className={classes.addressInput}
+                    />
+                  </Col>
+                </Row>
+                <Row margin="md">
+                  <Col xs={8}>
+                    <Field
+                      name="ownerAddress"
+                      component={TextField}
+                      type="text"
+                      validate={composeValidators(required, mustBeEthereumAddress)}
+                      placeholder="Owner address*"
+                      text="Owner address*"
+                      className={classes.addressInput}
+                    />
+                  </Col>
+                </Row>
+              </Block>
+              <Hairline />
+              <Row align="center" className={classes.buttonRow}>
+                <Button className={classes.button} minWidth={140} onClick={onClose}>
+                  Cancel
+                </Button>
+                <Button
+                  type="submit"
+                  className={classes.button}
+                  variant="contained"
+                  minWidth={140}
+                  color="primary"
+                  data-testid="review-tx-btn"
+                >
+                  Next
+                </Button>
+              </Row>
+            </React.Fragment>
+          )
+        }}
+      </GnoForm>
+    </React.Fragment>
+  )
+}
+
+export default withStyles(styles)(OwnerForm)
diff --git a/src/routes/safe/components/Settings/ManageOwners/ReplaceOwnerModal/screens/OwnerForm/style.js b/src/routes/safe/components/Settings/ManageOwners/ReplaceOwnerModal/screens/OwnerForm/style.js
new file mode 100644
index 00000000..bb4c1c1f
--- /dev/null
+++ b/src/routes/safe/components/Settings/ManageOwners/ReplaceOwnerModal/screens/OwnerForm/style.js
@@ -0,0 +1,38 @@
+// @flow
+import { lg, md, sm } from '~/theme/variables'
+
+export const styles = () => ({
+  heading: {
+    padding: `${sm} ${lg}`,
+    justifyContent: 'flex-start',
+    boxSizing: 'border-box',
+    maxHeight: '75px',
+  },
+  annotation: {
+    letterSpacing: '-1px',
+    color: '#a2a8ba',
+    marginRight: 'auto',
+    marginLeft: '20px',
+  },
+  manage: {
+    fontSize: '24px',
+  },
+  closeIcon: {
+    height: '35px',
+    width: '35px',
+  },
+  formContainer: {
+    padding: `${md} ${lg}`,
+    minHeight: '340px',
+  },
+  buttonRow: {
+    height: '84px',
+    justifyContent: 'center',
+  },
+  owner: {
+    alignItems: 'center',
+  },
+  user: {
+    justifyContent: 'left',
+  },
+})