FORM IV - ACKNOWLEDGEMENT SLIP - PREVENTION OF MONEY-LAUNDERING (FORMS, SEARCH AND SEIZURE OR FREEZING AND THE MANNER OF FORWARDING THE REASONS AND MATERIAL TO THE ADJUDICATING AUTHORITY, IMPOUNDING AND CUSTODY OF RECORDS AND THE PERIOD OF RETENTION) RULES, 2005

FORM IV [See sub-rule (5) of rule 8] ACKNOWLEDGEMENT SLIP Serial Number............. Received a sealed envelope bearing number................... dated........ from....................[designation of the authority] on.................[date] at............ [time] Signature of the Adjudicating Authority/designated officer of the office of Adjudicating Authority .................................. Name of the Adjudicating Authority/designated officer of the office of Adjudicating Authority [Office seal] To ................................................................................... [Name and designation of the authority] Address.............................. ................................................... ...................................................