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Reissue Request Form: Company Shares Held in Account Name Account Number Name of Bank

This document is a request form for a shareholder to reissue unclaimed dividend cheque(s). It contains the shareholder's details such as name, address, and shareholding information. It requests the company to reissue stale or unclaimed dividend cheques, noting a reissue fee will be deducted. It certifies the shareholder has not received the original cheques and will return any located cheques. Bank details are also provided to deposit future dividends directly. The shareholder authorizes the company to act on the instructions to reissue cheques and deposit future dividends in the nominated bank account.

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Rohit Verma
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© © All Rights Reserved
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Download as PDF, TXT or read online on Scribd
272 views

Reissue Request Form: Company Shares Held in Account Name Account Number Name of Bank

This document is a request form for a shareholder to reissue unclaimed dividend cheque(s). It contains the shareholder's details such as name, address, and shareholding information. It requests the company to reissue stale or unclaimed dividend cheques, noting a reissue fee will be deducted. It certifies the shareholder has not received the original cheques and will return any located cheques. Bank details are also provided to deposit future dividends directly. The shareholder authorizes the company to act on the instructions to reissue cheques and deposit future dividends in the nominated bank account.

Uploaded by

Rohit Verma
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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REISSUE REQUEST FORM

To:
The Share Registry,
_______ _____________ (Company Name)

RE: Request for Re-issue of Unclaimed Dividend Cheque(s)

I/We _______________________________ (name of shareholder) of _________________________


(address) being the registered holder of _______ (number of shares) in ______________ (company
name), hereby request you to reissue the unclaimed dividend cheque(s) which have become stale or
has not been claimed by me for other reasons. I/We also understand that there is a reissue fee which
will be deducted from the cheque(s) itself.

IN CONSIDERATION OF your Share Registry re-issuing the dividend cheque(s) as aforesaid, I/We
HEREBY CERTIFY that I have received the cheque(s) indicated above I request the cheque(s) be issued
to me at the above address. I understand that should I receive/locate the original cheque, I will return
it to the Central Share Registry Limited Office.

Section A – SHAREHOLDER DETAILS


SIN #: __________
Previous Address (if changed): _________________________________________________________
E-mail: _________________________________
Phone Contact: (H) ____________ (B) ______________ (M) _____________ (F) __________

Section B – BANK DETAILS


Should you require the cheques to be directly deposited into your nominated bank, please fill in the
table below:
Company Shares
Account Name Account Number Name of Bank
Held in

Please deposit all future dividends into the bank account as indicated above.

Section C – DECLARATION
I/We authorize you to act in accordance with my/our instructions set out above. I/We acknowledge
that these instructions supersede and have priority over all previous instructions relating to payments
of dividends to which I/We am/are entitled to be paid.
1. Individual/Joint or Group Shareholders:

________________ _______________ _______________


Shareholder 1 Shareholder 2 Shareholder 3
2. Company/Partnership and Trust Shareholders:

___________________ ___________________ _________________


Authorized Signatory 1 Authorized Signatory 2 Company Seal
----------------------------------------------------- FOR OFFICIAL USE----------------------------------------------------------------
Photo Id Received Shareholding Confirmation (Share Certificate/Dividend-
Prepared By: _____________________ Interest Advice/Correspondence/Tax Slip/Buy-Sell Order
Form)
Date Received: ______________________ Date Cheque(s) Printed: ______________________
Date Cheque(s) Posted: ______________________

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