Rematerialisation Request Form

ANNEXURE H
REMATERIALISATION REQUEST FORM
(pre-printed serial nos.)
PARTICIPANT NAME
DEPOSITORY PARTICIPANT - ID
RRN DATE
I/We hereby declare that the below mentioned account may be debited to the extent of my/our
rematerialisation request and equivalent certificates be issued for the same. I/We hereby declare
that the below mentioned person(s) are the beneficial owners of the securities mentioned.
Account No.
Account Holder Name
No. of Securities to be Rematerialised : (nos.)
(in words)
Lot Type Requested Market lot / Jumbo
Name of the Security
Name of Issuing Company
Face Value
ISIN
The rematerialisation request is for locked shares Yes/ No
Quantity :
Lock in Reason :
Lock in Release Date (dd-mm-yyyy)
Address : ( to be filled in only if change in address is to be recorded)
Pin
Authorised Signature(s)
Name Signature
First/Sole Holder
Second Holder
Third Holder
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Participant Authorisation
Received the above mentioned securities for rematerialisation from :
Account No.
ISIN
Date
Account No.
Name of the first holder
The application form is verified with the details of the beneficial owner’s account and certify that
the application form is in order. The account has sufficient balances to accept the rematerialisation
as requested. It is also certified that the beneficial owners signatures are verified and found in
order. The other details of the beneficial owners as extracted from the records are enclosed.
Forwarded by : (Seal)
Signature : ( Name of the Executive )
(to be printed from the system )
Remat Request No.
Status : Sub - Status : (Occupation) :
In Case of Individuals
Name(s) in full
First/Sold holder
Second holder
Third holder
In case of Corporates
Name
Full Address
Tax Information
PAN/GIR No. Circle/ward/district
Sole/First Applicant
Second Applicant
Third Applicant
Residential status : Resident / NRI
In Case of NRI Holding
Indian Address
Foreign Address
Nationality
RBI Approval No. Date
Bank Account No.
Lock in Reason
Lock in Release Date (dd-mm-yyyy)
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Acknowledgment
Participant’s Name Address and ID (pre-printed serial no.)
We hereby acknowledge the receipt of a rematerialisation request for __________ no. of shares
of ____________________________ (security details) from ______________ (Name) holding
a/c no. ___________ surrendered on _________(date) to be delivered in market lots / jumbo lots
of _________ certificates .
Participant’s Signature (Seal)