Form for Informant’s Voluntary Information Disclosure to be submitted to the Board

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..... elds are mandatory I. PERSONAL INFORMATION OF THE INFORMANT A.INDIVIDUAL 1: Last Name: First Name: Title: Address: City / State: PIN: Telephone (with State Code): Mobile: E-Mail address: Employment Details*: Permanent Account Number, if available: II. LEGAL REPRESENTATIVE (where applicable) Last Name: First Name: Title: Firm Name (if not self-employed): Contact address : City / State: PIN: Residence address: City / State: PIN: Telephone (with State Code): Mobile: E-Mail address: Bar Council Enrolment Number: III SUBMISSION OF ORIGINAL INFORMATION 1. Is it a violation of 3 [ insider trading laws ] ? Yes / No 2. If yes to question (1), please describe the type of violation: 3. Has the violation: Occurred / Occurring / Potential to occur in fu .....

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..... d copies of all the relevant documents. ] Please attach any additional documents to this form, if necessary. 11. Identify any documents or other information in your submission that you believe could reasonably be expected to reveal your identity and explain the basis for your belief that your identity would be revealed if the documents were disclosed to a third party. 12. Provide details of connection amongst the Informant, the company whose securities are involved and the person against whom information is being provided: IV. DECLARATION I/we hereby declare that,- I/we have read and understood the Securities and Exchange Board of India (Prohibition of Insider Trading) Regulations, 2015; I/we accept that mere furnishing of information by me .....

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..... alings with the Board, I/we knowingly and wilfully make any false, fictitious, or fraudulent statements or representations, or use any false writing or document knowing that the writing or document contains any false, fictitious, or fraudulent statement. Signature: . Date: dd/mm/yy Place: V. CERTIFICATE BY LEGAL REPRESENTATIVE (where the information is submitted through legal representative) I hereby certify as follows,- (a) I have reviewed the completed and signed Voluntary Information Disclosure Form for completeness and accuracy and the information contained therein is true, correct and complete to the best of my knowledge; (b) I have irrevocable consent from the Declarant, to provide to the Securities and Exchange Board of India, the or .....

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