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Form ISR-4: Request For Issue of Duplicate Certificate and Other Service Requests

This document contains a request form for the processing of investor service requests pertaining to securities held in physical form, such as issue of duplicate certificates, replacement/renewal of certificates, transmission, and transposition. The form requires the requester to provide mandatory documents and details like demat account details, PAN, specimen signature and nomination details. For a duplicate certificate request, the form asks for original certificate details like name of security holder, certificate numbers, distinctive numbers, number and face value of securities. The requester needs to select the specific service request and provide any additional documents needed for processing the request. It is declared that the information provided is true, and a letter of confirmation will be issued

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Nidhi Aggarwal
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4K views3 pages

Form ISR-4: Request For Issue of Duplicate Certificate and Other Service Requests

This document contains a request form for the processing of investor service requests pertaining to securities held in physical form, such as issue of duplicate certificates, replacement/renewal of certificates, transmission, and transposition. The form requires the requester to provide mandatory documents and details like demat account details, PAN, specimen signature and nomination details. For a duplicate certificate request, the form asks for original certificate details like name of security holder, certificate numbers, distinctive numbers, number and face value of securities. The requester needs to select the specific service request and provide any additional documents needed for processing the request. It is declared that the information provided is true, and a letter of confirmation will be issued

Uploaded by

Nidhi Aggarwal
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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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: / /2022

A. Mandatory Documents / details required for processing all service request:


I am 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): IN30115128170034

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 AIFPM4820R 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 request you for the following (tick  relevant box)

 Issue of Duplicate certificate □ Claim from Unclaimed Suspense Account


□ Replacement / Renewal / Exchange of securities □ Endorsement
certificate
□ Sub-division / Splitting of securities certificate □ Consolidation of Folios
□ Consolidation of securities certificate □ Transmission
□ Transposition (Mention the new order of holders here)
C. I am enclosing certificate(s) as detailed below**:

Name of the Issuer Company Bayer Cropscience Limited


Folio Number N0700411

Page No. 1
Name(s) of the security holder(s) as per the Nilu Mohindroo
certificate(s)
Certificate numbers 23863
Distinctive numbers 39521042 to 39521174
Number & Face value of securities 133 Equity Shares of FV of Rs.10/- each
** Wherever applicable / whichever details are available

D. Document / details required for specific service request:

 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 knowledge and belief.

Security Holder 1 / Claimant Security Holder 2 Security Holder 3


Signature

Name Nilu Mohindroo


Full H. No. – A- 18, Anand Niketan,
address Chanakya Puri s.o,
South West Delhi
Delhi
PIN 110021

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

Page No. 2
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.

Page No. 3

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