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..... 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 / C .....

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..... ther 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 th .....

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..... 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 proce .....

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..... 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, acceptan .....

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