| I. Personal Information of The Informant |
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A.Individual 1:Last Name:.....................
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First Name:..................... |
Title:.................. |
| Address: |
City / State: |
PIN: |
| Telephone (with State Code): |
Mobile: |
E-Mail address: |
| Employment Details*: |
Permanent Account Number, if available: |
| II. Legal Representative (where applicable) |
| Last Name:.................. |
First Name:........................ |
Title:.................. |
| Firm Name (if not self-employed): |
| Contact address : |
City / State: |
PIN: |
| Residence address: |
City / State: |
PIN: |
| Telephone (with State Code): |
Mobile: |
E-Mail address: |
| Bar Council Enrolment Number: |
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| III Submission of Original Information |
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1. Is it a violation of securities laws? Yes /No
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2. If yes to question (1), please describe thetype of violation:
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3. Has the violation: Occurred / Occurring /Potential to occur in future
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4. If the violation has occurred, date ofoccurrence: dd/mm/yy(in case exact date is not known, anapproximate period may be entered)
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5. Have the individual(s) or theirrepresentatives had any prior communication(s) or representationswith the Board concerning this matter? Yes (Details thereof) / No
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6. Does this violation relate to an entity ofwhich the individual is or was an officer, director, counsel,employee, consultant or contractor? Yes (Details thereof) / No
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7. If yes to question (6), was the originalinformation submitted first to your Head or internal legal andcompliance office? Yes / No
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8. If yes question (7), then please provide,Date of submission of original information: dd/mm/yy
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9. Please describe in detail why you think theinformation submitted is a violation?
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10. What facts or supporting material is yourallegation based on? Please attach any additional documents tothis form, if necessary.
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11. Identify any documents or other informationin your submission that you believe could reasonably be expectedto reveal your identity and explain the basis for your beliefthat your identity would be revealed if the documents weredisclosed to a third party.
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12. Provide details of connection amongst theInformant, the company whose securities are involved and theperson against whom information is being provided:
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| IV. Declaration |
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I/we hereby declarethat,-A. I/we have read andunderstood the Securities and Exchange Board of India(Prohibition of Insider Trading) Regulations, 2015;B. I/we accept thatmere furnishing of information by me/us does not by itself conferon me/us right to get reward and that I/we may not get any Rewardat all. I/we would be bound by the decisions that the authoritycompetent to grant reward may take;C. I/we accept thatthe Securities and Exchange Board of India is under no obligationto enter into any correspondence regarding action or inactiontaken as a result of my/our information.D. I/we accept thatthe reward would be an ex-gratia payment which, subject to theSecurities and Exchange Board of India (Prohibition of InsiderTrading) Regulations, 2015, shall be granted at the absolutediscretion of the competent authority. The decision of theauthority shall be acceptable to me/us and I/we shall notchallenge it in any litigation, appeal, adjudication, etc.E. In the event ofmy/our death before the reward us paid to me/us, it may be paidto ............. (Details of nominee)F. I/we declare thatthe information contained herein is true, correct and complete tothe best of my/our knowledge and belief and not obtained from thecategories of persons indicated in sub-regulation (2) andsub-regulation (6) of regulation 7G of the Securities andExchange Board of India (Prohibition of Insider Trading)Regulations, 2015 and agree to indemnify the Board in case it isnot so found. I/we fully understand that I/we may be subject toaction under securities laws as well as Section 182 of the IndianPenal Code, 1860 (45 of 1860) and ineligible for Reward if, inmy/our submission of information or in any other dealings withthe Board, I/we knowingly and wilfully make any false,fictitious, or fraudulent statements or representations, or useany false writing or document knowing that the writing ordocument contains any false, fictitious, or fraudulent statement.Signature:..............................Date: dd/mm/yyPlace:
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V. Certificate By Legal Representative (wherethe information is submitted through legal representative)
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I hereby certify asfollows,-(a) I have reviewed the completed and signed VoluntaryInformation Disclosure Form for completeness and accuracy and theinformation contained therein is true, correct and complete tothe best of my knowledge;(b) I have irrevocable consent from the Declarant, to provide tothe Securities and Exchange Board of India, the originalVoluntary Information Disclosure Form in the event of a requestfor it from the Securities and Exchange Board of India due toconcerns that the Informant has not complied with theseregulations or where the Securities and Exchange Board of Indiarequires the said information for the purpose of verification fordeclaring any gratuitous reward to the Informant or where theSecurities and Exchange Board of India determines that it isnecessary to seek such information to accomplish the purpose ofthe Securities and Exchange Board of India Act including for theprotection of investors, sharing with foreign securitiesregulators and foreign and Indian law enforcement agencies, etc.;(c) I am and shall continue to be legally obligated to providethe original Voluntary Information Disclosure Form without demurwithin seven (7) calendar days of receiving such request from theSecurities and Exchange Board of India.Signature:..................................Date: dd/mm/yyPlace:
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