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Dematerialisation Request Form

This document is a Dematerialization Request Form used to request the conversion of physical security certificates into electronic form for holding in a demat account. It contains fields to provide details of the depository participant, client, company, security type, certificate numbers, quantity and a signature authorization. The form also includes an acknowledgement receipt to be returned to the client confirming receipt of the certificates pending verification for dematerialization into the specified demat account.

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2K views2 pages

Dematerialisation Request Form

This document is a Dematerialization Request Form used to request the conversion of physical security certificates into electronic form for holding in a demat account. It contains fields to provide details of the depository participant, client, company, security type, certificate numbers, quantity and a signature authorization. The form also includes an acknowledgement receipt to be returned to the client confirming receipt of the certificates pending verification for dematerialization into the specified demat account.

Uploaded by

gurjanto69
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
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Annexure 11.

Dematerialisation Request Form


θ Normal Dematerialization θ Transmission-cum- Dematerialization
θ Transposition-cum-Dematerialization

Crimson Financial Services Ltd.


1 Karampura Shopping Center, New Moti Nagar, New Delhi- 110015
(To be filled up by the Depository Participant)
DRN Date D D M M Y Y Y Y
DRF No. Date D D M M Y Y Y Y

(To be filled by the BO. Please fill all the details in BLOCK LETTERS in English. Fill up a separate DRF
for Free securities and Locked – in securities. In case of locked - in securities fill up a separate DRF for
different lock-in reason / lock-in expiry dates.)

I / We request you to dematerialise the enclosed security certificate(s) registered in my / our name
into my / our demat account.

DP ID 1 2 0 3 5 9 0 0 Client ID
Name of the Company
ISIN I N
Quantity to be (In Figures)
Dematerialized (In Words)
Number Of Certificates (in words)
Nature of Securities θ Free Securities θ Lock-in Securities
Lock-in reason
Lock in Expiry Date D D M M Y Y Y Y

Details of Securities:
Type of Security θ Equity θ Debentures θ Bonds θ Units
θ Other (Specify)
Face Value of Securities
From To From To From To
Folio No.
Certificate Numbers
Distinctive Numbers
Quantity

Attach an annexure (duly signed by account holder(s)) in the above format if the space is not
sufficient.

The original certificates / documents are hereby surrendered by me / us for dematerialisation and the
same are free from any lien or charge or encumbrance and represent the bonafide securities of the
Issuer Company to the best of my / our knowledge and belief.

First / Sole Second Holder Third Holder


Holder
Name

Signature with DP

Signature with RTA

Participant Authorization (From DP to RTA)

We have received the above-mentioned securities bearing ISIN__________________ for Dematerialisation.


The Application form is verified with the Certificates / Documents surrendered for dematerialisation
and we certify that the application form is in accordance with the details mentioned in the enclosed
certificates / documents. It is also certified that the Holder(s) of securities have a beneficiary account
with us in the same name(s) and order of name(s).

Depository Participant Seal and Signature


Annexure 11.4

=========================(Please tear here)====


=======================
Acknowledgement Receipt

DRF No. Date D D M M Y Y Y Y


DP ID Client ID
First / Sole Holder Name
Second Joint Holder Name
Third Joint Holder Name
Name of the Company
Type of Security θ Equity θ Debentures θ Bonds θ Units
θ Other (Specify)
ISIN
No. of Securities (in figures)
No.of securities (in words)
No. of Certificates (in figures)
No. of Certificates (in words)

We hereby acknowledge the receipt of certificates / documents, in respect of the following securities
for dematerialization subject to verification: -

Depository Participant Seal and Signature

Instructions:

1. In case of transmission – cum – demat, a notarized copy of death certificate of the deceased
holder, copy of the order of the court etc. to be attached with DRF.

2. In case of transposition –cum –demat, a duly executed transposition request form to


be attached with the DRF.

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