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Rematerialisation Request Form

This document is an ICICI Bank Rematerialisation Request Form used to request the conversion of dematerialized securities back into physical certificate form. It provides instructions for filling out the form including details of the account holder, securities to be rematerialized, and applicable fees. Authorized signatures of the account holders are required to process the rematerialization request.

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Sukant Bhattacharya
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477 views1 page

Rematerialisation Request Form

This document is an ICICI Bank Rematerialisation Request Form used to request the conversion of dematerialized securities back into physical certificate form. It provides instructions for filling out the form including details of the account holder, securities to be rematerialized, and applicable fees. Authorized signatures of the account holders are required to process the rematerialization request.

Uploaded by

Sukant Bhattacharya
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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ICICI Bank Limited, CPC-Demat Services, Ground Floor, B-Wing, Autumn Estate, Chandivali Farm Road, Opp.

Mhada Colony, Chandivali, Andheri (East), Mumbai - 400072.


(Important Note : Please do not send requests directly to this address. Kindly route all your requests through the nearest ICICI Bank Demat Servicing Branches)

Rematerialisation Request Form (RRF)


For ICICI Bank use only RRN Date of Receipt : D D M M Y Y Y Y CPO SR. NO.

INDOC NUMBER SEQUENCE NUMBER Date D D M M Y Y Y Y

I/We hereby declare that the below mentioned account may be debited to the extent of my/our rematerialisation request and equivalent certificates
be issued for the same. I/We hereby declare that the below mentioned person(s) are the beneficial owners of the seurities mentioned.
TO BE FILLED UP BY HOLDER(S) Client ID

Account Holder Name


First/Sole Holder

Second Holder

Third Holder

No. of Securities to be Rematerialised (In figures) (In words)

Lot Type Requested

Market lot / Jumbo

Name of the Security Face Value: `

Name of Issuing Company ISIN

The Rematerialisation request is for locked shares Yes/No Lock in Release Date : D D M M Y Y Y Y
Quantity :

Lock in Reason :
Address : (to be filled in only if change in address is to be recorded)

Pin

CHARGES FOR REMATERIALISATION :

ICICI Bank Charges :


A Fees of ` 25 for every hundred securities or part thereof, subject to maximum fee of ` 3,00,000 or a flat fee of ` 25 per certificate, whichever is higher

Depository Remat Charges :


a) a fee of ` 10 for every hundred securities or part thereof subject to maximum fee of ` 5,00,000; or
b) a flat fee of ` 10 per certificate, whichever is higher.

AUTHORISED SIGNATURE(S) (If the signature registered with the Company/Registrar is different from the specimen signature given to the DP
please affix both signatures on the RRF)

Name Signature

First/Sole Holder
V-Dec 2017

Second Holder

Third Holder

PARTICIPANT AUTHORISATION
For ICICI Bank use only
Received the above mentioned securities for rematerialisation from.

Client ID ISIN Date D D M M Y Y Y Y

Name of the First Holder

The application form is verified with the details of the beneficial owner’s account and certify that the application from is in order. The account
has sufficient balances to accept the rematerialisation as requested. It is also certified that the beneficial owners signatures are verified and found in
order. The other details of the beneficial owners as extracted from the records are enclosed.
Forwarded by
For ICICI Bank Limited

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