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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 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 Distinctive Nos. To
  2. That 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. That 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. That 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. That 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 :

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): (1) (2) (3)
Signed before me
Place:
Date:
Signature of Notary with Official Seal of Notary & Regn. No.