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I _____________________________ W/O,S/O ______________________________ aged _________

years residing at
solemnly affirm and declare in favour of M/s _____________________________________________
(name and address of the Company)

1.That I am the sole holder of ________ number of equity shares in M/s. ______________________
as detailed below :

Folio No. No. of shares Certificate No. Dist.no.from Dist.no.to

2. That the above shares were acquired by me out of my own investment/funds against allotment in
public issue / market in the year ________.

3. That my name ______________________ registered under folio no. ________ as found in the
share certificate and the name ________________________________________ as found in demat
account ____________________ represent me, one and only person.

4. That my specimen signature given below be taken on record in respect of my holdings of

securities in the company as mentioned in para 1 in place of my existing signature in the Company’s

5. I hereby affirm that I shall not hold the Company or its Agents anyway responsible for any
consequences that might occur directly or indirectly on account of the Company or its Agents acting
on our request herein stated by dematerialsing the above said share to my above said demat
account and replacing the signature in the Company’s record and for the consequential acts/deeds
by the Company/its agent.

6. I hereby further affirm that the Transfer Deeds for sale of securities/Demat Request Form bearing
my signatures as appended hereinbelow can be taken as validly executed by me for all purposes, and
intents of transferring the ownership of securities held by me under the folios as stated in para 1

7. This Affidavit is executed in favour of the Company/its agents of my own volition and is in the
form as required by the Company/its agent forwarded to me vide its letter No. ________________,
dated ____________________.

I solemnly affirm that the statement contained in the above paragraphs are true to the best of my
knowledge, information and belief and that nothing material has been concealed from being
Solemnly declared and affirmed on DEPONENTS

Identification at ________________ 1.

On this ___________ day of 20 2.

Specimen signature
New sign : ___________________

Old sign : ____________________