FORM NO.

IEPF- 5 Application to the Authority for claiming

unpaid amounts and shares out of
Investor Education and Protaction Fund
(IEPF)
[Pursuant to sub-section (3) of section 125 of the
Companies Act, 2013 and rule 7(1) of the Investor
Education and Protection Fund Authority (Accounting,
Audit, Transfer and Refund) Rules, 2016]

Form language English Hindi

Refer instruction kit for details.

Note - All fields marked in * are to be mandatorily filled.

1. Particulars of the applicant

(a) * Name of the applicant

(b) * Address of the applicant

(c) Phone number

(d) Mobile number

(e) Email ID

2. Particulars of the Company / Bank from which the amount is due

(a)* Corporate Identification Number (CIN) of company / Pre-fill

Bank Corporate Identification Number (BCIN)

(b) Name of the company / bank

(c) Address of registered office of the company / bank

(d) email ID of the company / bank

3. Details of shares claimed

Folio No./ Total nominal

Category Kind of share Number of
shares amount of the share
DP ID - Client ID -
Account number
 4. Details of amount claimed

S.No. Particulars Amount (in Rupees)

(i) Dividend amount 0

(ii) Application money due for refund 0

(iii) Matured deposits with company

0

(iv) Matured debentures with company 0

(v) Interest accured on application money due for refund

0

(vi) Interest accured on matured deposits with company

0

(vii) Interest accured on matured debentures with company

0

(viii) Interest accured on dividend credited to IEPF under the Companies 0

Act, 1956

(ix) Sale proceeds of fractional shares arising out of issuance of bonus

shares, merger and amalgamation 0

(x) Redemption amount of preference shares 0

Others, specify
(xi) 0

Total 0

Note: If applicant doesn't have any information on amount claimed then the related column above may be left
blank

* Number of claims

Year wise details of securities/deposits for which the amount is claimed

Nature of claim Amount of the Financial year to Nature of Folio No. / DP Category Reason for non-
(1) claim which it relates security / ID - Client ID - (6) receipt / non-
(2) (3) deposit Account encashment of the
(4) number instrument of
(5) payment
(7)

5.* Aadhaar Number or Passport/OCI/PIO Card No. (in case of NRI/foreigners)

 6.* Details of Bank account (Aadhar linked, in case applicant is not NRI/foreigner)in which refund of claim to be made

(a) Bank account number

(b) Bank name

(c) Bank branch

(d) Type of account Saving Current

(e) IFSC code

7. Demat account number

Declaration

I declare that all the requirements of Companies Act, 2013 and the rules made thereunder in respect of the subject matter of
this form and matters incidental thereto have been complied with. I further declare that all the information given herein above
is true, correct and complete including the attachments to this form and nothing material has been suppressed.

*I understand that I, am the claimant and after filing the refund claim in this form online, shall to send the attachments
prescribed below to Nodal Officer (IEPF) of the company at its registered office in an envelope marked “claim for refund
form IEPF Authority” for initiating the verification for claim
1. Print out of duly filled claim form with claimant signature
2. Copy of acknowledgement
3. Indemnity Bond (original) with claimant signature

4. Advance Stamped receipt (original)

5. In case of refund of matured deposit or debenture, original certificate thereto

6. Copy of Aadhaar Card

7. Proof of entitlement (certificate of share/Interest warrant Application No. etc.)

8. Cancelled Cheque leaf

9. Copy of Passport, OCI and PIO card in case of foreigners and NRI

10. Other optional document,(if any)

Note: Attention is also drawn to provisions of Section 448 of Companies Act, 2013 which status that -

“Save as otherwise provided in this Act, if in any return, report, certificate, financial statement, prospectus, statement or other
document required by, or for, the purposes of any of the provisions of this Act or the rules made thereunder, any person makes a
statement,-

(a) which is false in any material particulars, knowing it to be false; or

(b) which omits any material fact, knowing it to be material,

he shall be liable under section 447.”

Modify Check Form Prescrutiny Submit

For office use only:

eForm Service request number (SRN) eForm filing date (DD/MM/YYYY)

Digital signature of the authorising officer

This e-Form is hereby approved

This e-Form is hereby rejected Confirm Submission

Date of signing (DD/MM/YYYY)