IFCI Infra Bond 2012 Application Form
IFCI Infra Bond 2012 Application Form
Form No.
1753536
Regd Office: IFCI Tower,61 Nehru Place, New Delhi-110019 Ph No.(011) 41792800,41732000; Website: www.ifciltd.com APPLICATION FORM FOR UNSECURED, REDEEMABLE, NON CONVERTIBLE IFCI LONG TERM INFRASTRUCTURE BONDS SERIES V ELIGIBLE FOR DEDUCTION UNDER SECTION 80CCF OF THE INCOME TAX ACT, 1961 UPTO Rs 20,000 FOR THE FINANCIAL YEAR 2011-12 (Please carefully read the Instruction overleaf and the Information Memorandum before filling up the form) ISSUE OPENS ON: February 29, 2012
ISSUE CLOSES ON : March 27, 2012
Brokers Name & Code Sub Broker code Bank Branch Sr.No.& Stamp For Use by collecting bank & branch
KISL
Dear Sirs,
310109
I (Cumulative) 8.50 % p.a 12 years 5th and 7th year (A) (B) (A)x(B) 5,000/II (Annual) 8.50% p.a 12 years 5th and 7th year 5,000/-
I/We have read and understood the Information Memorandum of Private Placement of Infrastructure Bonds Series V U/S 80CCF of Income Tax Act 1961. I/We bind myself/ourselves to their provisions and apply for allotment. Please place my/our name(s) on the register of Bond Holder(s). Options Interest Rate Tenor Buy back Facility (At the end of) Face Value & Issue Price(Rs./Bond) Number of Bonds applied Amount Payable(Rs.) Total Amount Payable(Rs.) Total Amount Payable (Rs. in words) Constitution of Applicant (Tick the appropriate box) Bond Certificate Mode (Tick the appropriate box) 1. Resident Indian Individual (Major) 1. Physical Mode 2. HUF 2. DEMAT Mode III (Cumulative) 8.72 % p.a 15 years 5th and 10th year 5,000/IV (Annual) 8.72 % p.a 15 years 5th and 10th year 5,000/Cheque/Demand Draft Details No. Date Drawn on (Name of Bank and Branch)
APPLICANTS DETAILS [ Name(s) should be in the same order as it appears in the demat account ] - Depository Participant details mandatory if applied for Demat mode
Depository Name DP NAME DP ID CLIENT ID First /Sole Applicants Name In Full (in capital letters) (Karta in case of HUF) Second Applicants Name In Full (in capital letters) Third Applicants Name In Full (in capital letters) Fathers/Husbands Name of First/Sole Applicant Address in Full of First/Sole Applicant Pin Code Telephone No.(with STD Code): BANK PARTICULARS Bank Name............................................................ E-mail id: Account No. Branch Name......................................................... FOR NECS/ECS PAYMENT 9 Digit Code number of the Bank & Branch appearing on the MICR cheque issued by the Bank (Please attach a Photocopy of Cheque or a Cancelled Cheque issued by your Bank for verifying the accuracy of the Code No.) NECS/ECS Mandate: YES Branch City/Town.. National Securities Depository Limited (NSDL) Central Depository Services (India) Limited (CDSL) For CDSL mention 16 digit Account number
N
Proof of Demat Account details may be attached to avoid mismatch
Important Note: In respect of bonds subscribed to in Demat form, the demographic details like address, bank account details, and nomination etc. shall be picked by the Registrar from the Demat Accounts of Applicant(s). For physical bonds, self attested copies of address proof, PAN Card and a cancelled or copy of cheque of the bank account mentioned above are to be attached.
Details of Nominee (For Individuals Only) Name... Name of Guardian (For minor applicant) Address Relation with Applicant... .. Date of Birth (if minor).... Signature of Nominee/Guardian (optional)........................................... SOLE/ FIRST APPLICANT PERMANENT ACCOUNT NUMBER SIGNATURE SECOND APPLICANT THIRD APPLICANT
PLACE: __________________________ DATE:__________________________ Disclaimer: The Bond issue is being made strictly on a private placement basis. It is not and should not be deemed to constitute an offer to the public in general. It cannot be accepted by any person other than to whom it is directed. -------------------- -------------------------------------------------------------------------------------------------TEAR HERE-------------------------------------------------------------------------------------------------------------.
DATE:
Form no.:
1753536
IFCI LIMITED, IFCI TOWER, 61 NEHRU PLACE, NEW DELHI 110 019 Received from ......................................................................................................................................................................... Address...................................................................an application for......................... number of IFCI Long Term Infrastructure Bonds- Series V having benefits u/s 80 CCF of Income Tax Act, 1961 upto Rs. 20,000/- for the year 2011-12 for investment of Rs... vide cheque/DD No..............dated........................drawn on ..........................................................................payable at..................................................................................... Note: Cheques/DDs should be drawn in favour of IFCI Limited- Infra Bond and crossed A/C Payee only. Please write Applicants Name, Phone No. & Application No. on reverse of the cheque/DD. Acknowledgement is subject to realisation of cheque/DD. Page 1 of 2
Page 2 of 2