ISMT : Form ISR - 4

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):

• • DematAccountNo.

  (Ifavailable):

  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 (seeSEBIcircular dated November 03, 2021 in this regard)

PAN

Nomination / Declaration to Opt-outSpecimen Signature

* (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 useForm ISR-1 inSEBIcircular dated November 03, 2021.

B.

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

• Issue of Duplicate certificate

  Claim fromUnclaimed

  Suspense

  Account

• Replacement / Renewal / Exchange of Endorsement securities certificate

• Sub-division / Splitting of securities Consolidation of Folios certificate

• 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 holder(s) as certificate(s) the security per the	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 / ClaimantSecurity Holder 2

Security Holder 3

Signature

Name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.