CLAIM FORM

Claim against

(Name of the Expelled / Defaulter member)

1. Personal Details *:
Salutation Mr/Ms/Msr
Name of the Claimant
Address

City/ Pin code

State
Telephone & Cell no.
(along with STD codes)

E-Mail id
PAN No.

Kindly provide a copy of the following documents:

PAN card
TM-Client registration form
KYC details

2. Trading account details *:

Client code

Kindly provide a copy of the following documents:

Ledger account statement.

Margin ledger account statement (wherever applicable).
Acknowledgement letter by TM towards the receipt of Margin money (wherever
applicable).

The above documents need to be provided for a period of at least 2 years prior to which the claim
has arisen.

3. Demat account details*:

Depository Participant Name

DP A/c No.

Kindly provide a copy of the demat account transaction statements for a period of at least 2
years prior to which the claim has arisen.

4. Bank Account Details *:

Bank Name
Branch Name
 Bank A/c No.

Kindly provide original bank certificate or certified bank account statement/ copy of passbook for
payments made by you (as reflecting in your ledger account statement) stating the following
information:-

Complete name of the party to whom payments were made.

The name of the account holder as well as the account number to which the payments
have been debited along with the date of debit.

5. Nature of Claim *:
CM^ claim (Rs.) F&O^ claim
A. Non-receipt of securities purchased NA
(Details to be enclosed as per format provided at Annexure 1, point A)

B. Non-receipt of funds on account of sale trades NA

(Details to be enclosed as per format provided at Annexure 1, point B)

C. Non- receipt of credit balance

D. Non- receipt of Margin

(Details to be enclosed as per format provided at Annexure 1, point C)

a) Provided in form of funds

b) Provided in form of securities

E. Corporate benefits on securities kept with trading member

(Details to be enclosed as per format provided at Annexure 1, point D
for CM segment and point E for F&O segment)

F. Total claim amount

6. Additional documents to be enclosed along with the claim form:

i. Copy of contract notes pertaining to the claim.

ii. Any other documents.

7. Details of complaint taken up with Trading Member (TM) (if any)

i. Complaint letter date

ii. Copies of correspondence with the TM
iii. Mode of communication
8. Details of complaint taken up with the Exchange (if any)

i. Complaint no. provided by the Exchange

ii. Status of complaint

9. Details of complaint filed through SEBI SCORES (if any)

i. SCORES ref.no
ii. Status of complaint

10. Arbitration details (if any)

i. Arbitration matter no.

ii. Status of Arbitration matter

11. Details of the case / Additional information

Please state, whether you are a registered sub-broker or authorized person?

YES / NO

If yes, please specify your registration no. and SEBI code.

______________________________________

Are you related to the employee / proprietor / partners / directors of the trading member?

YES / NO

If yes, please provide the details.

Declaration:

I hereby declare that,

I have disclosed all my transactions and I do not owe any amount to the trading member.
The claim pertains to the undersigned only and that is not made on behalf of any other
person.
All the information provided by me is true to the best of my knowledge and I am aware that
my claim is liable to be rejected if the information given by me is found to be false or incorrect.

Place: _____________
Date: ______________
(DD- MM-YYYY) Claimants Signature

* Mandatory details
 General Instructions for CM and F&O segment claim:

a. Please read the entire document carefully before filling up the details.
b. Please provide complete details in respect of your claim, as per the format specified in the Annexures.
c. Please provide your complete Personal details ie: address, pin-code contact numbers, PAN no. so that
Exchange can get in touch with you in case additional information is required.
d. Ensure that the following mandatory documents have been provided by you along with the claim form.
Copy of Ledger account statements
Copy of Margin ledger account statements (wherever applicable)
Acknowledgement letter by TM towards the receipt of Margin money (wherever applicable).
Copy of Demat account transaction statements
Bank certificate/ certified bank statement or pass book for payments made to TM.
Copy of contract notes pertaining to the claim.
Copy of PAN card.
Copy of Member Constituent agreement
Copy of KYC details submitted to the TM.
e. All the documents submitted by you should pertain to the same period. (ie. period of at least 2 years prior
to which the claim has arisen.)
f. In-case the claimant is a company, in addition to the above documents, please provides copy of board
resolution providing names of authorized signatories, and list of all the directors/ shareholders/promoters
of the company.

Please note that Exchange would not consider:

1. Contract in securities, which are not made subject to the Bye-laws, Rules and Regulations of the
Exchange.

2. Claims for trades that are not executed on Exchange.

3. Claims arising out of any arrangement of settlement (in lieu of bonafide dues) for trade executed on the
Exchange.

4. Claims which are in the nature of a loan, with or without security.

5. Claims which are received after the due date from the date of publication of the notice inviting claims.

6. Claims not supported by adequate documents in respect of payments made to / received from trading
member and also securities delivered / received, etc.

7. Loss emanated from delayed delivery of securities.

8. Claim for the interest on the amount claimed.

9. Claim for damages / harassment / miscellaneous charges.

10. Claims of investors whose unique client code are not registered with Exchange.

11. Claims where documents are not received within the specified time period as intimated by the
Exchange.

12. Claimants holding arbitration awards / IGRP awards in their favour will be treated at par with the other
claims and be independently evaluated by the Relevant Authority.

13. In case of review request, more than 2 review requests or cases where review documents are not filed
with the Exchange within 90 days of receipt of intimation from the Exchange.

Abbreviations used:

PAN - Permanent Account Number

TM - Trading Member
DP - Depository Participant
KYC - Know Your Client
CM - Capital Market Segment
F&O - Futures and Options Segment
 ***********

Annexure 1

Details of claim

Nature of Claim:-

A. Non-receipt of securities purchased-

i. Please provide in the following format, the list of securities which have not been received by you on purchase,
and attach copies of contract notes in support of your claim.

S. no. Name of the Qty. Rate Value (Rs) Contract Date of contract Settlement
security note no. note no.
purchased

ii. Please provide in the following format , details of payment along with proof of payment ie. bank certificate,
certified bank account statement/ copy of passbook for purchase of the above securities.

S. Particulars Bank name Account no. Cheque Date of Name of Amount (Rs.)
no. no. payment payee

iii. Please provide in the following format, details of securities sold (if any) for purchase of the securities
mentioned above in point (A i), and attach copies of contract notes for the sale transactions in support of your
claim.

S. Name of the Qty. Rate Value Contract Date of contract Settlement no.
no. security sold (Rs) note no. note

iv. Please provide in the following format ,details of proof of delivery of securities sold ie. demat account
transaction statement (evidencing that the securities sold are delivered) as specified above in (point A iii), for
paying towards purchase of securities as mentioned in point (A i).

S. Name of the Qty. Date of Beneficiary Name of the Names of the Beneficiary
no. security sold delivery Account Depository Participant Account Holders
No.

B. Non-receipt of funds on account of sale trades

i. Please provide in the following format ,the list of securities sold by you for which you have not received
payments and attach copies of contract notes in support of your claim.

S. Name of the Qty. Rate Value Contract Date of contract Settlement

no. security (Rs) note no. note no.

ii. Please provide in the following format, details of proof of delivery of securities sold (ie. demat account
transaction statement evidencing that the securities sold have been delivered) as specified by you above in (B
i).

S. Name of the Qty. Date of Beneficiary Name of the Names of the

no. security delivery Account No. Depository Beneficiary Account
Participant Holders
C. Non- receipt of Margin

i. Non-receipt of funds provided as margin

Please provide in the following format , details of payments along with proof of payment ie. bank certificate,
certified bank account statement/ copy of passbook paid to TM towards margin money.

S. Particulars Bank name Account no. Cheque Date of Name of Amount (Rs.)
no. no. payment payee

ii. Non-receipt of securities provided as margin

Please provide in the following format , details of securities delivered along with proof of delivery ie. demat
account statement (evidencing that the securities are delivered) towards margin money.

S. Name of Qty Rate Amount Date of Beneficiary Name of the Names of the
no. the (Rs.) delivery Account No. Depository Beneficiary
security Participant Account holders

D. Corporate benefits on securities kept with trading member- CM segment

Please provide in the following format, the details of the securities for which corporate benefit is claimed.

S. Name of Symb Type of Date of purchase of Ex-date of Qty Rate Amount

no Security ol corporate securities corporate (Rs.)
benefit benefit

E. Corporate benefits on securities kept with trading member- F&O segment

Please provide in the following format, the details of the securities for which corporate benefit is claimed.

S. Name of Symbol Type of Date of transfer of Ex-date of Qty Rate Amount

no Security corporate securities corporate (Rs.)
benefit benefit

Any other information/ details about your claim: