Application For Refund Page 2
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1
2APPLICATION FOR REFUND
Affix a
(
)
Please use ball point pen only
recently
Sub :
My investments in Sahara India Real Estate Corporation Ltd (SIRECL) and/or Sahara Housing Investment
taken
Corporation Ltd (SHICL).
passport size
photo here
I hereby submit Application for Refund of my investment in the aforesaid Sahara Companies. The details are as under:
1. Name of the Bondholder
:
2. S/o / D/o / W/o / C/o. :
3. Occupation :
4.Telephone (with STD Code) / Mobile No.:
5. Email Id :
6. PAN Number, if available (please attach a copy of PAN)
:
@
7. Address
If located in Urban Area, in the following format
If located in Rural Area, in the following format
House/Flat no., floor,
Village name
premises name, block no.
Street, Landmark, Sub
Post office name
locality
Locality, Road, sector,
Tehsil and District
Town / City
State
State
Pin code
Pin code
@
If the above Address is different from the Address mentioned in the Original Bond Certificate/ Passbook issued by Sahara, please furnish Address proof for both the Addresses.(Please refer to Instructions
Sl.No.2)
1.
Details of investments
(Please fill details in appropriate boxes below)
Investments in Sahara India Real Estate Corporation
Investments in Sahara Housing Investment Corporation Ltd.
Description
Ltd.
Real Estate
Nirmaan
Abode
Multiple
Income
Housing
Account Number /
Control Number
No. of Bonds
Amount invested
Mode Of Investment
$
(Cash / Cheque / DD)
$
In case of Investment by Cheque/DD please indicate Cheque /DD No., Date, Drawee Bank and Branch, and in case of Cheque please attach relevant copies
of Bank Statement/Passbook evidencing payment by cheque.
2.
Bank Account Details
Name of the Bank and Branch
Name of the Account holder
Account No.
Type of Account:
Savings /
Current Account (Please tick)
IFSC Code
UNDERTAKING
I/We ________________________________________ declare that the information given in this application form is true to the best of my / our
knowledge and belief. In consideration of the refund of the aforesaid amount to me/us by SEBI pursuant to the Orders of the Hon'ble Supreme
Court of India dated August 31, 2012, December 5, 2012 and May 8, 2013, I/We hereby undertake to return the said amount along with applicable
interest to SEBI, If my/our aforesaid declaration is subsequently proven to be false. Further, I/We shall also be liable for any civil or criminal
actions in accordance with the law.
Place
:
Date
:
.................................................
Signature / Thumb Impression
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