4. This Is to Request to Execute the Operation on Writing Off the Following Securities

/
(495)787-44-83 / The order to execute operation in the Register
Entering No / Entering No /
Date / Date / Date
Accepted / Accepted / Executed

Issuer: ______

(Full name of the issuer)

1.The person, whose account securities are written off: / Account number
holder / nominee holder / trustee / deposit account / treasury account of the issuer
Surname Middle Name/ full name
Name of the document(type)
Series, number(PSRN) / Date of Issue
Name of the body delivering, registering document / Subdivision code

2. Authorizedrepresentativedata, whoseaccountthesecuritiesarewrittenoff

Surname Name Middle name
Name of the document(type)
Series, number / Date of issue
Name of the body delivering document / Subdivision code
Grounds for authority
3. The person, whose account securities are enlisted to / Account number
holder / nominee holder / trustee / deposit account / treasury account of the issuer
Surname Middle Name/ full name
Name of the document(type)
Series, number(PSRN) / Date of issue
Name of the body delivering, registering document / Subdivision code

4. This is to request to execute the operation on writing off the following securities

Type / category (type)) / State registration number of securities issue
(shares/bonds) / (common share/preference share)
non-encumbered / encumbered(encumbrance type, grounds for encumbrance):
Amount ______(______)
(in writing)
Transaction price______(______)
(in writing)
Grounds for securities transfer:
(Name and requisites of contracts/ any other documents)
Creditordata(to be specified in a case of securities transfer into the deposit account –full name of the creditor, information about registration):
Creditor information is missing / Way of transaction calculation : / cash payment / non-cash payment

5. Beneficiary data:

the client acts to his own benefit / the client acts to benefit of other person
To fill in the form: "Data on the beneficiary of the client of the legal entity" or "The annex to the Application form of the registered person for individuals the Application form for detection of data according to the requirement of the Federal law of 07.08.2001 No. 115-FL "About counteraction of legalization (laundering) of income gained in the criminal way, and to financing of terrorism""
Signature of the person, whose account the securities are written off CB(authorized representative)
______«_____» ______20___year.
(number and date of the power of attorney)
______/______
(подпись М.П. Ф.И.О.) / Signature of the pawnbroker
(authorized representative))
______«_____» ______20___year.
(number and date of the power of attorney)
______/______
(signature company stamp Surname/name/ middle name) / Signature of person, whose account the securities are enlisted to
(authorized representative)
______«_____» ______20____г.
(number and date of the power of attorney)
______/______
(signature company stamp Ф.И.О.)

The order is provided:

______

(signature, surname/name/middle name

Date of filling: ______