Affidavit for Loss of original Share Certificates - Grasim

To
AFFIDAVIT
(by the Registered Shareholder)
(Only for shares held in Physical form)
(To be executed on a non-judicial stamp of Rs.10/-)
Grasim Industries Limited
Share Department
Birlagram, Nagda (M.P) 456 331
Dear Sir,
Re: Loss of Share Certificates held in Physical Form
I/We ___________________________ S/o. ____________________ aged ______ years and
________________________________ S/o. ____________________ aged ________ years
residing at _________________________________________________________________
__________________________________________________________________________
___________________________________________________________________________
__________________________________________ solemnly affirm and declare as follows:
1. That I/we am/ are the sole/ joint holder/s of _______ number of Equity Shares in Grasim
Industries Limited.
Folio
No.
Certificate No(s).
Distinctive Nos.
From
To
No. of Shares
2. That the above shares were acquired by me/ us for valuable consideration out of my/ our
own investment/ funds in the year(s) ________________.
3. That I/we have not pledged the original certificate(s) by way of security or collateral or
otherwise have not sold the above mentioned shares anytime to any person.
4. That the stop transfer instructions given by me/ us are not on the grounds of the nonpayment
by my/ our Broker/ Sub broker.
5. That I/we have genuinely lost/ misplaced the above mentioned shares.
6. That I/we am/ are solely responsible for any future liabilities in respect of the above
mentioned securities.
7. This Affidavit is executed in favour of the Company on my/ our own volition and is in
the form as required by the Company and forwarded to me/ us vide its letter No.
___________ dated ___________________.
C:\DOCUME~1\ADMINI~1\LOCALS~1\Temp\Affidavit for Loss of original Share Certificates.doc

VERIFICATION
I/We solemnly affirm that the statements contained in the above paragraphs are true to the
best of my/ our knowledge, information and belief and that nothing material has been
concealed from being disclosed.
Solemnly declared and affirmed on
identification at ____________________
on this _______________ day of 200____
Deponents
1.
2.
Before the Executive Magistrate or
Notary Public
C:\DOCUME~1\ADMINI~1\LOCALS~1\Temp\Affidavit for Loss of original Share Certificates.doc