Form ISR - 3
Declaration Form for Opting-out of Nomination
by holders of physical securities in Listed Companies
(see SEBI circular No. SEBI/HO/MIRSD/MIRSD_RTAMB/P/CIR/2021/655 dated November 03, 2021 on Common and Simplified Norms for processing investor’s service request by RTAs and norms for furnishing PAN, KYC details and Nomination)
[Under Section 72 r/w Section 24 (1) (a) of Companies Act, 2013 r/w Section 11(1) and 11B of SEBI Act, 1992 and Clause C in Schedule VII and Regulation 101 of SEBI (Listing Obligations and Disclosure Requirements) Regulations, 2015)]

Name of the Company :
Registered Address of the Company :
I / we
the holder(s) of the securities particulars of which are given hereunder, do not wish to nominate any person(s) in whom shall vest, all the rights in respect of such securities in the event of my /our death.
PARTICULARS OF THE SECURITIES (in respect of which nomination is being opted out)

Nature of Securities Folio No. No. of Securities Certificate No. Distinctive No. From Action
I/ we understand the issues involved in non-appointment of nominee(s) and further are aware that in case of my / our death, my / our legal heir(s) / representative(s) are required to furnish the requisite documents / details, including, Will or documents issued by the Court like Decree or Succession Certificate or Letter of Administration / Probate of Will or any other document as may be prescribed by the competent authority, for claiming my / our aforesaid securities.
Name(s) and Address of Security holders(s) Signature(s)
Sole / First Holder Name
Second Holder Name
Third Holder Name
Name and Address of Witness Signature