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.... The Securities and Exchange Board of India/ Ombudsman (* give address of the office of the Board or the address of the Ombudsman having jurisdiction......) Dear Sir, Sub: Complaint against .........................(Name of the listed company / intermediary) 1. NAME OF THE COMPLAINANT .................. 2. FULL ADDRESS OF THE COMPLAINANT ........................ ..................

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....................................................................... 6. DETAILS OF THE COMPLAINT (If space is not sufficient, please enclose separate sheet) ..................................................................................................................... ...... 7. (a) Whether any reply (Within a period of one month after the listed company / intermediary concer....

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....l the documents) 10. DECLARATION 1. I/ We , the complainant/s herein declare that: (a) the information furnished herein above is true and correct; and (b) I/ We have not concealed or misrepresented any fact stated in aforesaid columns and the documents submitted herewith. 2. The complaint is filed before expiry of period of one year reckoned in accordance with the provisions of the ....

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....nding .... ) and the proceedings are likely to take longer time in its final adjudication as contemplated in the Regulations. 1. I/We authorise the listed company / intermediary to disclose any such information/ documents furnished by us to the Securities and Exchange Board of India /Ombudsman and disclosure whereof in the opinion of the Securities and Exchange Board of India/ Ombudsman is nece....