INVESTOR COMPLAINT FORMAT
(Use separate forms for each company / complaint) 
(Please tick the appropriate item and complete all columns in Capital Letters) 

To,
SECURITIES & EXCHANGE BOARD OF INDIA
Investor Grievance & Guidance Division,
P.B. No. 19972, Nariman Point P.O.
Mumbai (Bombay) - 400 021.

Dear Sirs, 
Kindly take up the matter with the Company for immediate redressal of my complaint, particulars of which are as under : 

1. Name of the Investor 
    (Compulsory)		 : 
    Address of the Investor 
    (Compulsory)		 : 
2. Name of the Company 
    (Compulsory)		 : 
    Address of the Company 
    (Compulsory)		 : 
3. Email Address (Investor) : 
4. Name of the Registrar & 
    Transfer Agent (if any) 		 : 
5. SEBI Acknowledgement
     Reference No.
    (in case of reminder) 		 : 
6. Nature of Complaint
    Type / Category
    (i) Issue / Offers - 
        non-receipt of
 : Refund Order / Allotment Advice 
: Revalidation of Refund Order (RO) 
: Duplicate RO for correct amount 
: Duplicate RO after Indemnity 
: Cancelled Stock Invest (S.I.) 
: RO after details furnished 
: Copy of encashed RO 
: Duplicate RO for correct bank details 
: Allot against encashed S.I. 
: Duplicate RO after correction 
: Short Refund 
    (ii) Dividend - 
          non receipt of
 : Dividend 
    (iii) Shares - 
          non receipt of 
          certificates 
          in/after 
 : Exchange of allotment letter 
: Conversion 
: Splitting 
: Transfer 
: Endorsement 
: Bonus 
: Transmission 
: Consolidation 
: Duplicate on submission of indemnity bond 
    (iv) Debentures / 
          Bond - 
          non receipt of 
          certificates 
          in/after 
 : Interest 
: Transfer 
: Consolidation 
: Redemption Amount 
: Transmission 
: Splitting 
: Exchange of Allotment Letter 
: Endorsement 
: Duplicate on submission of indemnity bond 
: Interest on delayed interest payment 
: Interest on delayed redemption amount 
    (v) Miscellaneous - 
         non receipt of 
 : Annual Report 
: Interest on delayed refund payment 
: Brokerage/Commission payment 
: Offer for Rights 
: Interested on delayed divident 
: Any other (specify below) 
  
: Registration of change in address 
: Non-listing of securities on stock exchange 
7. Particulars of the 
    application/securities 
    held
    (a) Full name of first 
          applicant / 
          security holder 
 : 
    (b) Application form 
          No. / Folio No.
          (Seller's in case 
          of Transfer) 
 : 
    (c) No. of Securities 
          applied / held 
 : 
    (d) Kind of Security 
 : 
    (e) Mode of payment 
          details
 : 
: No.  Dated 
  Drawn on 
    (f) Application 
        deposited at 
 : 
    (g) Bank serial No.
 : 
    (h) Original refund 
          order No. 
          (in case of 
          revalidation / 
          duplicate )
 : 
    (i) Period on / for 
         which dividend /
         interest / maturity
         amount / 
         redemption 
         amount due
 : 
    (j) Date on which 
        securities were
        forwarded to 
        Company / 
        Registrars
 : 
    (k) Indemnity Bond 
         sent for issue 
         of duplicate 
 : If Yes, Date : 
8. Other details if any, 
     in brief 		  
9. Dates of earlier 
    correspondence 
    with the Company / 
    Registrars 		 : 

NOTE: It would be advisable to address the complaints to SEBI only if Company / Registrars has not responded inspite of having sent two reminders over a period of atleast one month. 
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