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CIN: U65191TN1991PLC021815

I / We have read and understood the contents of information memorandum of Private Placement and accompanying term sheet for issue of
Secured Non-Convertible Redeemable Debentures of 1,000/- each. I / We apply to allot me / us the debentures as per details given below.
On allotment, please include me / us on the register of debenture holders. I / We bind myself / ourselves by the terms and conditions as
contained in the memorandum of private placement and of this form.

TYPES OF DEBENTURE 1 Amount of Debenture Rs.......................in words...................

(Tick which ever is applicable) ...............................................................................................
Cheque / DD No...................................Date..............................
Bank........................................................................................

2 Sole / First Applicant (IN CAPITAL LETTERS)

...............................................................................................
General Senior Citizen
S/o., W/o & D/o.......................................................................
Address..................................................................................
......................................................Post.................................
Pin
Land/
PAN
Mobile
Date of Birth............................................Age (in Years)......................................
*0.5% Extra for Senior Citizens Email.....................................................................................................................

3 Permanent Address...................................................................................................................................
.....................................................................................................................................................................
Post..................................Pin Land/ Mobile

5 Sole/ Third Applicant (in CAPITAL LETTERS)...............................................................................................

S/o, W/o & D/o.......................................................................Address............................................................
................................................................................................................................................................
Post.................................................................Pin PAN

Land /Mobile Date of Birth......................................... Age (in Years)...............

CIN: U65191TN1991PLC021815
 Details of Bank Account (Sole/First Applicant) :............................................................................................................................................
Account Number : .........................................................Bank :.......................................................................................................................
Branch : ..........................................................................IFSC Code :...........................................................................................................
Status of Sole/First Applicant : On Redemption Please pay the proceeds to :
Individual Company
Former or Survivor
Trust Other

TDS : Signature
Sole/First Applicant.........................................................................
Not to be deducted (Form 15H/15G en-closed)
Second Applicant............................................................................
To be deducted
PAN Card No..................................... Third Applicant................................................................................
Form No. SH-13
Nomination Form
[Pursuant to section 72 of the companies Act, 2013 and rule 19(1) of the Companies
(Share Capital and Debuntures) Rules 2014]
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ICL Fincorp Limited
No.61/1, First Avenue,
VGP Apartments, Ground Floor,
Ashok Nagar, Chennai - 600083

I ....................................................................................................................the applicant(s) of the secured non-convertible Debunture wish to make

nomination and do hereby nominate the following persons in whom shall vest, all the rights in respect of such securities in the event of my/our death.

(1) PARTICULARS OF NOMINEE/S-

(a) Name: (b) Date Of Birth:

(c) Father’s/Mother’s/spouse’s name: (d) Occupation:

(e) Address: (f) Phone:

(g) E-mail id: (h) Relationship with the security holder:

(3) IN CASE NOMINEE IS A MINOR-

(a) Date Of Birth: (b) Date of attaining majority:

(c) Name of guardian: (d) Address of guardian:

Signature of the Nominee Signature of the applicant(s)

* ID proof of the nominee to be compulsory attached

(FOR OFFICE USE)

Date of Receipt of Application.....................................................Date of Realization of Payment .............................................

Acknowledgement No. ...........................................................................................Bond No.......................................................
Interest % applicable............................................. Monthly Interest Amount (if opted for)............................................................

Date of redemption.......................................................................Ledger folio No.......................................................................

Checked by..................................................................................................................................................................................

Authorised Signature