Form A - Declaration to be submitted by the investors to the depository participants for availing the benefits under the Rajiv Gandhi Equity Savings Scheme. - Rajiv Gandhi Equity Savings Scheme, 2012

1 [Form A [See paragraph 5(b)] Declaration to be submitted by the investors to the depository participants for availing the benefits under the Rajiv Gandhi Equity Savings Scheme. Name of the Investor: (first holder) Address of the investor: Permanent Account Number (PAN): 1. It is hereby certified that*--- (a) I do not have a demat account and I have not traded in any derivatives. (b) I have demat account no ................ in ........................ depository participant but I have not traded in any equity shares or derivatives in this account. (c) I have a joint demat account no ....................... in ........................ depository participant but I am not the first account holder. 2. I hereby declare that I have read and understood all the terms and conditions of the Rajiv Gandhi Equity Savings Scheme. 3. It is hereby verified that I am an eligible new retail investor for availing the benefits under the Rajiv Gandhi Equity Savings Scheme. 4. I undertake to abide by all the requirements and fulfil all obligations under the Scheme, and will comply with all the terms and conditions of the Scheme. 5. I understand that, in case I fail to comply with any condition specified in the Scheme, the benefits availed thereunder will be withdrawn and the tax shall be payable by me accordingly. Signature of the Investor Place: Date: *Tick whichever is appropriate. ] ----------------------- Notes:- 1. Inserted vide Notification No. 51/2012, dated 23/11/2012