This affidavit is to be executed in the presence of a Public Notary [To

FORM –A

AFFIDAVIT

[For issuance of duplicate securities]

Note: This affidavit is to be executed in the presence of a Public Notary

[To be submitted in non-judicial stamp paper of appropriate value]

I/We,_______________________________________________________

Son / daughter/spouse of ____________________________________________________

residing at

_______________________________________________________________________________

______, having Permanent Account No (s) ______________________________do hereby

solemnly affirm and state on oath as follows.

1. That I/We, _________________________________________

(“all the shareholders ”) hold

the following (number of) securities under Folio no. _____ in (name of the company)

in my/ our name as single holder / joint holder:

Company

Name

Folio No.

No. of

securities

held

Security

Certificate

No.

Distinctive Nos.

From

To

1)

2)

3)

2. I/We_____________________________________________________________________

further swear / solemnly declare that I/ we am/are applying for issue of duplicate certificate(s) to

me/us on the ground that the original security(ies) certificate(s) has/have been misplaced / not

found by me/us, despite a diligent search made by me/us in this behalf.

3. I/We_______________________________________________________________________

further swear /solemnly declare that the said securities are not sold or pledged or deposited by

way of security to any person/company.

4. I/We________________________________________________________________________

_______hereby further swear / solemnly declare that if, after the duplicate share certificate(s) is

/ are issued to us as aforesaid, the original security(ies) certificate(s) is / are at any time

subsequently, found, recovered or traced by us or by anyone on our behalf, then, we

unconditionally undertake not to deal with the said original share certificate(s) in any manner

whatsoever (whether by physical transfer or dematerialization or as security or pledge) and further

unconditionally undertake to promptly surrender the original share certificate(s) to the RTA /

Company, for cancellation.

5. I/We _________________________________________________________am/are making the

above solemn declaration on oath with full knowledge of the fact that in the event the original

security (ies) certificate(s) issued is /are found, recovered and traced by me/us and instead of

surrendering the same is / are dealt with by me/us as aforesaid, the Company will be at liberty to

adopt civil and / or criminal proceedings against me/us for my/our failure to promptly surrender

the original security (ies) certificate(s), for cancellation and for breach of my/our solemn

declaration and undertaking not to deal with the original security (ies) certificate(s) in any manner

whatsoever as aforesaid at my/our entire risk as to cost and consequences.

Signature of all deponents : X________________

________________

VERIFICATION

We hereby solemnly affirm and state that what is stated herein above is true to our

knowledge and nothing has been concealed therein and that we are competent to contract

and entitled to rights and benefits of the above mentioned securities.

Deponent(s) (1) ____________(2) __________________(3) ____________________

Solemnly affirmed at ______________________

Signature of the Deponent(s): X____________________________

_______________________________________________________________________________

Signed before me

Place: __________________________

Date : ___________________________

X --------------------------------------------------

Signature of Notary with Official Seal of Notary & Regn.

No.

Form-B

INDEMNITY

[For issuance of duplicate securities]

Note: This indemnity is to be executed in the presence of a Public Notary / Gazetted

Officer

[To be submitted in non-judicial stamp paper of appropriate value]

I/We,______________________________________________________________Son

/ daughter / spouse / of ______________________________________ residing at

_____________________________________________________________________

_______________ having Permanent Account No (s)

______________________________do hereby solemnly affirm and state on oath as

follows.

1. That I/we, am/are the sole/joint holder/s of the Securities in following folios. I/We request

you to issue duplicate certificate(s) for securities, as detailed below in my/our name(s):

**In case of non-availability of Certificate Nos./Distinctive Nos./ Folio nos., security holder shall obtain the same

from RTA.

2. That the above securities were acquired by me/us for valuable consideration out of

my/our own investment/funds against allotment in Public Issue/allotment in Right Issue

or acquired from the market/through inheritance in the year(s) ………….

3. I/We hereby jointly and severely agree and undertake to indemnify and keep indemnified,

saved, defended, harmless, the aforesaid (Name of the Company/RTA) and its

successors and assigns for all time hereafter against all losses, costs, claims, actions,

demands, risks, charges, expenses, damages, etc., whatsoever which you may suffer

and/or incur by reason of your, at my/our request, issuing the said Duplicate Securities

as herein above mentioned, to the undersigned.

Name of the

Company

Certificate No.**

Distinctive No.**

Folio No. **

No. and Face

value of

securities held

1

2

3

4

IN WITNESS WHEREOF the said 1) Mr. /Ms. _______ (Name and signature of the

witness) ____________________________

And 2) Mr. /Ms. ________________________ Name and signature of the witness

______

#

, have hereunto set their respective hands and seals this day of

_____________________________

Signed before me

at: __________________________

on:: ___________________________

Signature of Notary / JMFC

Official stamp & seal of the Notary Magistrate/ Notary & Regn. No.:

Address of First holder / Applicant :

_____________________________________

______________________________________

Pincode

Tel. No.

Email id

Signature of All holder(s) / Applicant(s) :

___________________________________

____________________________________

FOR OFFICE USE ONLY

Signature checked by :

Page 1 of 4

Form ISR-4

(Refer circular No. SEBI/HO/MIRSD/MIRSD_RTAMB/P/CIR/2022/8 dated January 25,

2022 on Issuance of Securities in dematerialized form in case of Investor Service

Requests)

Request for issue of Duplicate Certificate and other Service Requests

(for Securities - Shares / Debentures / Bonds, etc., held in physical form)

Date:___ /___ /______

A. Mandatory Documents / details required for processing all service request:

I / We are submitting the following documents / details and undertake to request

the Depository Participant to dematerialize my / our securities within 120 days from

the date of issuance of Letter of Confirmation, received from the RTA/Issuer

Company (tick as relevant, refer to the instructions):

• Demat Account No. (If available):  

Provide Client Master List (CML) of your Demat Account from the Depository

Participant*

• Provide the following details, if they are not already available with the RTA (see SEBI

circular dated November 03, 2021 in this regard)

PAN

Specimen Signature

Nomination / Declaration to Opt-out

* (Your address, e-mail address, mobile number and bank details shall be updated in your

folio from the information available in your CML). You can authorize the RTA to update

the above details for all your folios. In this regard, please refer to and use Form ISR-1 in

SEBI circular dated November 03, 2021.

Page 2 of 4

B. I / We request you for the following (tick  relevant box)

 Issue of Duplicate certificate

Claim from Unclaimed Suspense

Account

 Replacement / Renewal / Exchange of

securities certificate

 Endorsement

 Sub-division / Splitting of securities

certificate

 Consolidation of Folios

 Consolidation of Securities certificate

 Transmission

 Transposition (Mention the new order of holders here)

C. I / We are enclosing certificate(s) as detailed below**:

Name of the Issuer

Company

Folio Number

Name(s) of the security

holder(s) as per the

certificate(s)

1.

2.

3.

Certificate numbers

Distinctive numbers

Number & Face value of

securities

** Wherever applicable / whichever details are available

D. Document / details required for specific service request:

I.  Duplicate securities certificate

Page 3 of 4

II.  Claim from Unclaimed Suspense Account

Securities claimed

(in

numbers)

(in words)

III.  Replacement / Renewal / Exchange of securities certificate

(that is defaced, mutilated, torn, decrepit, worn out or where the page on the

reverse is fully utilized)

IV.  Endorsement

V.  Sub-division / Splitting of securities certificate

VI.  Consolidation of securities certificate/Folios

VII.  Transmission

VIII.  Transposition

Provide / attach original securities certificate(s) for request for item numbers III to VIII

above.

Declaration: All the above facts stated are true and correct to best of my / our knowledge

and belief.

Security Holder 1 / Claimant

Security Holder 2

Security

Holder 3

Signature



Name



Page 4 of 4

Full

address





After processing the service request, the RTA shall issue a ‘Letter of Confirmation’ to the

securities holder/claimant, which is valid only for 120 days. Using this ‘Letter of

Confirmation’, the securities holder/claimant shall request the DP to dematerialize the

securities, failing which the securities shall be credited to the Suspense Escrow Demat

Account of the Company.