FOR OFFICE USE ONLY
Date of receipt Of application
Date of clearance of cheque
To
Water and Sanitation Pooled Fund
Dear Sirs, Date..: ______
Sub: Private Placement of Unsecured Redeemable Non-Convertible Tax Free Pooled Finance Development Bonds under Pooled Finance Development Fund Scheme of Government of India by Water and Supply Sanitation Pooled Fund in the nature of Promissory notes of Rs. 10 lakhs each for cash at par aggregating Rs. 45 crores
Having read and understood the contents of the memorandum of Private Placement, I/We apply for allotment to me/us of the Bonds. The amount payable on application as shown below is remitted herewith. On allotment, please place my/our name(s) on the Register of Bondholders under the issue. I/We bind myself/ourselves by the terms and conditions as contained in the Memorandum of Private Placement.
Financial Institution / Mutual Fund / NBFC/ RNBFCCompany / Religious/Charitable Trust / Commercial Bank/RRB/Co-op. Bank
Insurance Company / Provided/Superannuation/Gratuity Fund / Other Please specify
______
Tax status of the Applicant (please tick one)
1. Non Exempt / 2. Exempt Under Self Declaration Under Statute Under Certificate from I.T. AuthorityBonds Applied For:
No: of Bonds (In figures) / PARTICULARS OF Demat A/CNo: of Bonds (In words) / DP ID
Amount (Rs.) (In figures) / Client ID
Amount (Rs.) (In words)
Date / Cheque/Demand Draft drawn on (Name of the Bank and Branch)
(Please include Bank’s RTGS code IFSC code of the branch) / Cheque / Demand Draft No / Date of Receipt of Application
FIRST APPLICANT’S NAME IN FULL :
SECOND APPLICANT’S NAME IN FULL (if applicable) :
FIRST APPLICANT’S ADDRESS IN FULL :
Pin :
Contact Person / Tel No. / Fax No.
First Applicant’s PAN / IT Circle/Ward/ District
I/We hereby agree to abide by the terms and conditions governing the Bonds. I/We further agree to the allotment in full or part of the Bonds applied for in this form.
Name of Authorised Signatory / Designation / Signature1.
2.
………………………………………………………………………………………………………………………………………………………………………
ACKNOWLEDGMENT SLIP(To be filled in by Applicant) / / WATER AND SANITATION POOLED FUND
(Fund manager of WSPF : Tamil Nadu Urban Infrastructure Financial Services Limited)
112, Sir Theyagaraya Road, 1st Floor,
Vairam Complex T. Nagar, Chennai 600017
Ph- (044) 28153104, 28153105 Fax no. - (044) 28153106
Website:- www.tnudf.com / Application Form Serial Number:
Received from M/s. / Mr. / Mrs.______
Cheque/Draft Nos.______dated ______drawn on ______
for Rupees. ______Being the subscription amount for ______No. of Bonds applied for
INSTRUCTIONS
1. Application forms must be completed in full in BLOCK LETTERS IN ENGLISH. A blank space must be left between two or more parts of the name.
A / B / C / D / E / L / T / DSignatures should be made in English or in any of the Indian languages. Thumb impressions must be attested by an authorised official of a Bank or by a Magistrate/ Notary Public under his/ her official seal.
2. Application forms duly completed in all respects must be submitted with the respective Collecting Banker. Cheque(s)/ Demand Draft(s) should be drawn in favour of “WSPF Tax-free Pooled Bond Issue A/c” and crossed “Account Payee Only”. Cheque(s)/ Demand draft(s) may be drawn on any bank including a co-operative bank, which is a member or a sub-member of the Banker’s Clearing House located at Kolkata, Chennai, New Delhi, Mumbai, Bangalore, Hyderabad, Thiruvananthapuram, Ahmedabad and Pune.
3. Outstation Cheques, cash, money orders, postal orders and stockinvest shall not be accepted.
4. As a matter of precaution against possible fraudulent encashment of interest warrants due to loss/misplacement, applicants are requested to mention the full particulars to their bank account, Bank’s RTGS code IFSC code of the branch as specified in the Application Form. Bank will try to remit the interest warrants through electronic transfer or Interest warrants will then be made out in favour of the bank for credit to the applicant’s account. In case the full particulars are not given, cheques will be issued in the name of the applicant at his/ her risk.
5. Receipt of applications will be acknowledged by the respective Collecting Branch of the Bank in the “Acknowledgment Slip”, appearing below the Application Form. No separate receipt will be issued.
6. All applicants should mention their Permanent Account Number allotted under Income-Tax Act, 1961 and the Income-Tax Circle/Ward/District. In case where neither the PAN number has been allotted, the fact of non-allotment should be mentioned in the application form in the space provided.
7. The application would be accepted as per the terms of the Scheme outlined in the Information Memorandum for Private Placement.