MANAGERS/BROKERS TO THE FIXED DEPOSIT SCHEMES

23353480

66623300

23508430

PHONES: 011-43577100, 39913100, 39913112, 43577112, 41519394 FAX: 011-43577420 Email: sect@ansals.com Website : www.ansals.com

(CIN: L45201DL1983PLC016821)

(CREDIT RATING : “IND tA-” WITH INVESTMENT GRADE)

g) Deposit will be accepted by crossed “A/c Payee” Cheques/Drafts made in favour of “ANSAL HOUSING & CONSTRUCTION LTD.”

22,314

21,022

24,900

28,194

AXIS BANK LTD.148, Barakhamba Road, New Delhi-110001Current A/c. No. 910020025926657

BANKER TO THE FIXED DEPOSIT SCHEME

INVITES UNSECURED FIXED DEPOSITS

201372

.Regd. Office: 15 UGF, Indra Prakash, 21, Barakhamba Road, New Delhi - 110 001 Phones: 011-43577100, 39913100, 39913112, 43577112, 41519394 Fax: 011-43577420 E-mail: sect@ansals.com Website : www.ansals.com

BROKER'S NAME AND ADDRESS

APPLICATION FORM FOR UNSECURED FIXED DEPOSIT

Note: (a) Please write in Block letters, (b) Kindly tick (P) appropriate box for items 1-6 & 8, (c) In case of other items please write only one letter in each box, leave one box blank between words.

I/WE HEREBY APPLY FOR A FIXED DEPOSIT WITH YOUR COMPANY AS PER DETAILS GIVEN BELOW:

1. SCHEME

2. PERIOD

3. INTEREST PAYABLE

4. CATEGORY OF SOLE/FIRST APPLICANT

5. STATUS OF SOLE/FIRST APPLICANT

6. INCOME TAX EXEMPTION

:

:

:

:

:

QUARTERLY CUMULATIVE DEPOSIT

SIX MONTHS

MONTHLY INCOME DEPOSIT

1 YEAR 2 YEARS 3 YEARS

QUATRERLY ON MATURITY MONTHLY

PUBLIC SHAREHOLDER (Folio No....................................) OTHERS

RESIDENT INDIVIDUAL HUF TRUST OTHERS

YES NO (IF YES, ATTACH FORM NO. 15H/15G IN DUPLICATE)

7. PERMANENT ACCOUNT NO. (MANDATORY)

8. THE REPAYMENT OF DEPOSIT SHOULD BE

MADE PAYABLE TO

9. AMOUNT

10. MODE OF PAYMENT

11. APPLICANT NAMES (In order of first name/middle name/surname)

SOLE/FIRST NAMED DEPOSITOR EITHER OR SURVIVOR ANY ONE OR SURVIVOR

RS.......................................RUPEES.................................................................................................

CHEQUE/DD NO. .......................... DATED..........................DRAWN ON.......................................

RENEWAL OF FDR NO...............................................................DATED.........................................

MR./MRS./MISS/MASTER SOLE/FIRST APPLICANT

MR./MRS./MISS/MASTER SECOND APPLICANT

MR./MRS./MISS/MASTER THIRD APPLICANT

12. ADDRESS OF SOLE/FIRST APPLICANT (Please do not write the name again)

(PBox if Minor)

PIN

13. SIGNATURE OF APPLICANT(S) (Guardian*, In case of minor)

SOLE/FIRST APPLICANT...................................................... PHONE NO(S).................................................................................................................................

*NAME OF GUARDIAN...................................................................................................................

RELATIONSHIP WITH MINOR........................................................................................................

DATE OF BIRTH OF MINOR..........................................................................................................

DATE............................................. PLACE.............................................. .........................................

SECOND APPLICANT......................................................

THIRD APPLICANT..........................................................

DECLARATIONS: 1. l/We hereby declare that the amount being deposited herewith is not out of any funds acquired by me/us by borrowing or by accepting deposits from any other person.2. l/We hereby declare the first named depositor mentioned in the application is the beneficial owner of this deposit and as such he/she should be treated as the payee for

the purpose of deduction of tax at source under section 194A of the Income Tax Act, 1961.3. l/We hereby solemnly declare that as on the date of this application, l/We, have no amount of deposits or loans with the Company (Whether originally paid in cash or

otherwise) remaining unpaid (whether repayment has fallen due or not), which by itself or taken together with the present application is Rs. 20,000/- or more, in terms of Section 269SS of the Income-Tax Act, 1961 (applicable only in case of application made in cash and not made by "A/c payee" cheques/demand drafts).

4. l/We have read carefully and agree to abide by the terms and conditions of the Company's Fixed Deposit Scheme given to me/us separately and declare that what is stated in the application is true and correct Please acknowledge and send me/us a Fixed Deposit Receipt on realisation of Cheque(s)/Draft(s).

NOMINATION (Must be signed by the depositor(s) & witnessed)I/We nominate the following person to whom in the event of my/our/minor's death the amount of this deposit may be returned by the company.

Name & Address of nominee : Relationship withDepositor (If any)

Age ofnominee

Date of Birth of nominee (if minor)

*As the nominee is a minor on this date, I/We appoint (Name, address & age)

to receive the amount of the deposit on behalf of the nominee in the event of my / our / minor's death during the minority of the nominee.

*Leave out if nominee is not a minor. Where deposits are made in the name of a minor, the nomination should be signed by a person lawfully entitled to act on behalf of the minor

Name(s), and Address(es) of witness(es) for nomination only. (One witness is mandatory for nomination)

SIGNATURE OF DEPOSITOR(S) FOR NOMINATION

FIRST/SOLE/

GUARDIAN

SECOND

THIRDSignature of witness(es) Place & Date

MR. FATHER/HUSBAND NAME (FIRST APPLICANT)

(CIN: L45201DL1983PLC016821)

SHAREHOLDER (Client ID/DPID No...............................................)

FOR OFFICE USE ONLY (Not to be filled in by the applicant)

RECEIVED DATE BROKER CODE SCHEME CODE

FDR NO. PAY IN SLIP DATECHEQUE REALISED ON

(PLEASE ENCLOSE A COPY OF PAN CARD)

Received from Fixed Deposit for Rs.____________________________________Vide Cheque/Draft/Cash/Renewal_________________________________

Ms./Mr. ____________________________________________________Dated _____________________________drawn on________________________________________

Address__________________________________________________as deposit for_________________Months under scheme A/B/C received on_______________________

____________________________________________________Pin Code __________________________

.

Regd. Office: 15 UGF, Indra Prakash, 21, Barakhamba Road, New Delhi - 110 001

Company's Stamp

ACKNOWLEDGEMENT RECEIPT