| Form ISR-4 |
| (see 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. |
| 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 |
| 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 Signature |
|
| Security Holder 2 Signature |
|
| Security Holder 3 Signature |
|
| Full address |
|
| PIN |
|
| 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. |
