Small Estates Statement And Indemnity Form
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Small Estates Statement and Indemnity
Please return this form to the
registrar of the issuer
Company, Trust, Warrant or Product in which investment is held
Full Name(s) of Registered Holding
Account Designation
Registered Address
Securityholder Reference Number
(SRN) OR Share Certificate Number
A
SMALL ESTATE STATEMENT AND INDEMNITY
Please use a BLACK pen using capital letters. Photocopies will not be accepted.
1. Description of Securities (Shares, Options etc.)
2. Number if Securities held
I/We do solemnly and sincelry declare I am/we are the legal representative(s) for the above deceased estate
.
3. Full name(s) of Executor(s) or Administrator(s)
4. Address of Executor(s) or Administrator(s). Only one address can be recorded.
Postcode
5. I/We request the security issuer to permit transmission of the securities detailed above to ourselves as legal representative(s) of the estate
without requiring a Grant of Probate or Letter of Administration or reseal of grant of probate to be obtained in the state of:
(Australian State or Territory where the securities are registered)
In consideration of the security issuer registering the securities in my/our name(s). I/We herby covenant to indemnify and forever keep indemnified the security
issuer, the directors and trustees of the security issuer, the security registrar and the directors and officers of the security registrar from and against all losses
respect thereof and all clains, actions, proceedings, demands and costs and expenses whatsoever which may be made or brought agains them by
in
reson of compliance with this request.
6.
Contact Name
Contact Mobile Number
Email
B
SIGNATURE(S) OF EXECUTOR(S)/ADMINSTRATOR(S) THIS MUST BE COMPLETE
Executor/Administrator
Executor/Administrator
Executor/Administrator
Witness
Witness
Witness
The witness(es) certifies that the person(s) who has/have signed this statement is/are known to
them and has/have signed in the presence of the witness with their normal signature(s)
Date:
C
HOW TO COMPLETE THIS FOR M
A.
Small estates statement and indemnity – Enter the following in the spaces provided:
1. A brief description of the type of securities.
4. The address details to be entered on the
5. The Australian State or
2. The number of securities held in figures.
register. Please note only one address can
Territory where registered.
3. The name of Executor(s) of Administrator(s).
be recorded (delivery of correspondence).
6. Contact name and number.
Important notice: If the holding is a broker sponsored holding in CHESS, do not send this completed form to registrar. You
must contact the sponsoring broker to lodge a Request to Register Surviving Holder(s) form.
B. Signature – all surviving holder(s) must sign
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