SCHEDULE - I - Application for settlement - Securities and Exchange Board of India (Settlement of Administrative and Civil Proceedings) Regulations, 2014

SCHEDULE-I (See regulation 3) Part-A FORM Application for settlement (For Office use only) Date of receipt of the application: Application Registration Number: ( Instructions : All the particulars must be filled. Put NA wherever necessary.) Before the Securities and Exchange Board of India In the matter of .. 1. Name/Trade name of the applicant: (a) Registration no., if applicable : (b) Date of Registration, if applicable : (c) PAN number: (d) Paid-up capital of applicant: 2. If stock broker, name of the stock exchange: 3. If sub-broker, name of stock broker with whom affiliated and name of the stock exchange: 4. Name of the segment (Cash/derivative etc.): 5. Form of organization: corporate body/ sole proprietorship / partnership / LLP/ financial institution (if listed co., details of listing) : 6. Names of promoters/directors/proprietors/partners: 7. Key management personnel(s) : 8. Address/correspondence address, contact no./fax no. and email(any changes in aforesaid details shall be communicated to the Board promptly): 9. Name and contact details (including e-mail) of the contact person (s): 10. Other registration(s) with the Board, if applicable : (a) Trade name : (b) Registration type : (c) Registration no. : 11. Case(s) pending with the Board/SAT/Court (Pl. specify) : 12. Case(s) pending under 11B/Adjudication/Enquiry/others (pl. specify): 13. Stage at which pending: 14. Interim order(s) in the pending proceedings (gist of the orders passed), if any : 15. Other actions pending with/concluded by the Board, if any (with their details) : (a) Against the applicant : (b) Against its associates : (c) Against its key management personnel(s) : (d) Against its other promoters/directors: (e) Other details, if any: 16. Date of show cause notice/summons/communication indicating probable cause of action, if any, against which the settlement is sought(PLEASE ENCLOSE COPIES)*: 17. Full and true disclosure of facts (including the profit made, loss avoided, gross fees, brokerage, commissions, etc., in respect of the cause of action): 18. Specific charges alleged: 19. Terms of settlement proposed by the Applicant:- (a) Monetary terms:- (b) Non-monetary terms:- 20. Original documents to be enclosed: (a) Undertakings and waivers (as per Format specified in Part C). (b) Authority letter/Board resolution. 21. List of other enclosures: (a) A copy of the notice to show cause/summons/communication/other notices indicating the probable cause of action, if any, against which the settlement is sought; (b) Complete Annual Reports / other relevant financial details for the last three financial years and the quarterly audited financial results of the current year; (c) A statement showing net worth of the applicant(only for those applicants who are required to comply with the networth requirements as specified by the Board or by the stock exchanges), gross annual income before tax, the amount of gross profit made/loss avoided, including the gross brokerage, fees, management/performance/transaction fee, carried interest, compensation, etc., in respect of the said default; (d)Copy of PAN card; (e) Complete Income-tax Returns of the applicant for the last three financial years; (f) Any other relevant document (s)/submissions. (Signature of the applicant) (Stamp and Seal) Verification I, son/daughter/wife of (Name in block letters) Shri ..being the applicant/authorised representative (in case of corporate entity) of . do hereby verify and affirm on oath that this this application and the contents thereof are true to my knowledge and belief and as per the records and that I have not suppressed any material facts. (Signature of the applicant) Date: Place : Part-B [Every applicant shall pay processing fees of ten thousand rupees and every application for condonation shall be accompanied with additional processing fees of two thousand rupees, by way of a demand draft in favour of 'Securities and Exchange Board of India' payable at Mumbai or by way of direct credit in the bank account through NEFT/RTGS/IMPS or any other mode allowed by RBI.] 1 Part-C Undertakings and Waivers Format Undertaking to be submitted alongwith the application with stamp duty duly paid and duly notarized at the time of execution. I/We, , the applicant(s) herein, as a condition for making the enclosed application to the Board for examining of the application and passing of appropriate settlement order, hereby declare that I/we agree and undertake that: (1) I/We admit the jurisdiction and right of the Securities and Exchange Board of India to initiate appropriate proceedings in respect of the alleged default. (2) I/We further agree and undertake that the time spent during the settlement proceedings shall be excluded for computing the limitation period, if any, for initiating or continuing or restoring any legal proceedings, if any, against me/us, and waive any objections in this regard. (3) The Securities and Exchange Board of India may enforce any claims against me/us arising from or/in relation to any violation of the settlement order passed pursuant to this application. (4) Nothing in the settlement order shall preclude any other person from pursuing any other legal remedy to which such person may be entitled against me/us as per law. (5) The settlement proposed by me/us does not limit or create any private rights or remedies for any person who is not a party to these proceedings, against me/us. (6) The settlement amount including legal costs, if any, shall be paid by me/us to the Board within the period stipulated by the Board. (7) The settlement order shall be construed and enforced in accordance with the Securities and Exchange Board of India (Settlement of Administrative and Civil Proceedings) Regulations, 2014. (8) I/We agree that subsequent to the passing of the settlement order, I/We shall not take any action or make or permit to be made any public statement denying, directly or indirectly, any finding in the settlement order or creating impression that the settlement order is without factual basis. (9) I/We hereby declare that nothing in the waiver and undertaking given by me/us shall affect my/our (i) testimonial obligations or (ii) right to take legal or factual positions in defence of litigation or in defence of a claim or in any other legal proceeding in which the Board is not a party. (10) I/We admit the findings of fact and conclusions of law or neither admit nor deny the findings of fact and conclusions of law (strike off whichever is not applicable) which may be part of the settlement order, and agree to abide by the settlement order as may be passed for the purpose of settlement of the specified proceedings in accordance with the Securities and Exchange Board of India (Settlement of Administrative and Civil Proceedings) Regulations, 2014 and guidelines and circulars issued by the Board in that regard. (11) I/We waive my/our right of taking any legal proceedings against the Securities and Exchange Board of India concerning any of the issue covered in the settlement order that may be passed. (12) I/We further waive the following: (a)the findings of fact and conclusions of law; (b) the proceedings before the Board or any officer of the Board; (c) the right to all post-hearing procedures; (d) appeal/review before the Tribunal/courts; (e) any plea relating to such provisions of the regulations or other requirements of law as may be construed to prevent any officer of the Securities and Exchange Board of India from participating in the any proceedings, including settlement proceedings or assisting or advising the internal committee, high powered advisory committee or panel of whole time members, as to, any order, opinion, finding of fact, or conclusion of law, etc; (f) any plea of bias or pre-judgment by the Securities and Exchange Board of India or the high powered advisory committee, based on the consideration of or discussions concerning settlement of all or any part of the internal proceedings; (g) any plea of limitation for initiating or reopening of the proceedings, if the applicant violates the settlement order. (Signature of the applicant with stamp and seal of the body corporate) Before me. Notary. ******** 1 Substituted vide the Securities and Exchange Board of India (Settlement of Administrative and Civil Proceedings) (Amendment) Regulations, 2017 w.e.f. 27.02.2017. Prior to substitution the existing item read as under: Every applicant shall pay fees of ten thousand rupees by a demand draft in favour of 'Securities and Exchange Board of India payable at Mumbai. Prior to the SEBI (Settlement of Administrative and Civil Proceedings) (Amendment) Regulations, 2014, the existing item read as under: Every applicant shall pay fees of five thousand rupees by a demand draft in favour of 'Securities and Exchange Board of India payable at Mumbai.