SCHEDULE - FORM - Securities and Exchange Board of India (Ombudsman) Regulations, 2003

SCHEDULE FORM [Under regulation 14 of the Securities and Exchange Board of India (Ombudsman) Regulations, 2003] (FOR OFFICE USE ONLY) Complaint No. of year .. Date .. (TO BE FILLED UP BY THE COMPLAINANT) To The Securities and Exchange Board of India/ Ombudsman (* give address of the office of the Board or the address of the Ombudsman having jurisdiction ) Dear Sir, Sub: Complaint against .(Name of the listed company / intermediary) 1. NAME OF THE COMPLAINANT 2. FULL ADDRESS OF THE COMPLAINANT PIN CODE .. PHONE NO. / FAX NO. 3. COMPLAINT AGAINST (NAME AND FULL ADDRESS OF THE LISTED COMPANY / INTERMEDIARIES ) . . PIN . PHONE NO. / FAX NO. . 4. (a) DATE OF REPRESENTATION / COMPLAINT BY THE COMPLAINANT TO THE LISTED COMPANY / INTERMDIARY . (Please enclose three copies of the representation) (b) Whether any reminder was sent by the complainant? YES /NO (If yes, please enclose three copies of the reminder) 5. SUBJECT MATTER/GROUNDS OF THE COMPLAINT (Please refer to regulation 14 of the Regulations) .. 6. DETAILS OF THE COMPLAINT (If space is not sufficient, please enclose separate sheet) 7. (a) Whether any reply (Within a period of one month after the listed company / intermediary concerned received the representation) has been received? YES / NO (If yes, please enclose three copies of the reply of the listed company / intermediary) (b) Whether the representation has been rejected ? YES/ NO (If yes, please enclose three copies of the letter of rejection) (c) Whether the complainant has received any other final decision of the listed company /intermediary? YES/ NO (If yes, please enclose three copies of the letter of the listed company/intermediary conveying its final decision) 8. NATURE OF RELIEF SOUGHT FROM THE OMBUDSMAN ( Please enclose three copies of documentary proof, if any, in support of your claim) 9. LIST OF DOCUMENTS ENCLOSED (Please enclose three copies of all the documents) 10. DECLARATION 1. I/ We , the complainant/s herein declare that: (a) the information furnished herein above is true and correct; and (b) I/ We have not concealed or misrepresented any fact stated in aforesaid columns and the documents submitted herewith. 2. The complaint is filed before expiry of period of one year reckoned in accordance with the provisions of the Regulations. 3. (a) The subject matter of the present complaint has never been brought before the Office of the Securities and Exchange Board of India /Ombudsman by me/ or by any one of us or by any of the parties concerned with the subject matter to the best of my/ our knowledge. a. The subject matter of the present complaint is not in respect of the same which was settled through the Office of the Securities and Exchange Board of India /Ombudsman in any previous proceedings b. The subject matter of the present complaint has not been decided by any forum/court/arbitrator. OR The subject matter of the present complaint is pending since .. (please mention the date when the matter was filed) before (*Please mention the name of the forum/court/arbitrator before whom pending . ) and the proceedings are likely to take longer time in its final adjudication as contemplated in the Regulations. 1. I/We authorise the listed company / intermediary to disclose any such information/ documents furnished by us to the Securities and Exchange Board of India /Ombudsman and disclosure whereof in the opinion of the Securities and Exchange Board of India/ Ombudsman is necessary and is required for redressal of any other complaint or our complaint. 2. I/We have carefully gone through the provisions of the Securities and Exchange Board of India (Ombudsman) Regulations, 2003. Yours faithfully (Signature) (Complainant ) NOMINATION / AUTHORISIATION (If the complainant wants to nominate/authorise his representative, not being a legal practitioner, to appear and make submissions on his behalf before the Securities and Exchange Board of India/ Ombudsman or to the Office of the Securities and Exchange Board of India/ Ombudsman, the following declaration should also be submitted.) I/We the above named complainant/s hereby nominate Shri/Smt .. who is not a legal practitioner and whose address is as my/our REPRESENTATIVE in all proceedings of this complaint and confirm that any statement, acceptance or rejection made by him/her shall be binding on me/us. He/She has signed below in my presence. ACCEPTED (Signature of Representative) (Signature of Complainant)