LOOSE DIS SLIP REQUEST Date:

To, The Branch Manager Kotak Mahindra Bank Ltd, 5th Floor, Vinay Bhavya Complex159-A, CST Road, Kalina, Santacruz (E) Mumbai: 400 098.

Sub: Issuance of Loose Instruction slip.

Please supply me/us with ________________ Instruction slip for executing my/our DP transaction’s. I / We agree that the instruction slip will be collected across the counter at my/our risk and consequences . I / We shall not hold KOTAK MAHINDRA BANK LTD. liable in any manner whatsoever in respect of bank processing the loose slip issued in the below mentioned account.

DP ID IN302814 CLIENT ID: _______________________

Name / Names of the Account Holder / s: Signature / s of the Holder / s

Sole / First Holder: ______________________ ________________________

Second Holder : ______________________ ________________________

Third Holder : ______________________ ________________________

Address: ________________________________________________________________

_______________________________________________________________________

Reasons: ________________________________________________________________

Note Loose slips will be issued in Emergency case subject to the following: o All Account holder (s) need to sign on the Requisition slip. o All Account holder (s) have to come personally to the nearest branch. o Photo identification documents are required for all the holder (s).. o Latest Transaction statement of the Demat account to be provided. _______________________________________________________________________

(For bank use only)

Serial no. of the delivery Instruction slip no. Issued: ___________________________

Officer: Approved By: Comments:

Name: _______________ Name:________________ __________________

Sign: _________________ Sign: _________________ __________________