Regulation SCHEDULE E - Form for Informant’s Reward Claim to be submitted to the Board within the time specified in the intimation of prima facie eligibility to receive an Informant Reward. - Securities and Exchange Board of India (Prohibition of Insider Trading) Regulations, 2015

1 [SCHEDULE E [See regulations 7D and 7E] Form for Informant s Reward Claim to be submitted to the Board within the time specified in the intimation of prima facie eligibility to receive an Informant Reward. All fields are mandatory I . PERSONAL INFORMATION A. Informant: Last name:--------------------- First Name:------------------------ Title:----------------- Address: City / State: PIN: Telephone (with State code): Mobile: E-Mail Address: Employment Details: Permanent Account Number: II ORIGINAL INFORMATION SUBMITTED Online Acknowledgment Receipt Number: (Annex Original Form for Voluntary Information Disclosure, if not yet submitted to Securities and Exchange Board of India) Subject matter of submission: Date of submission: dd/mm/20 Case Name: SEBI Order No.: Date: dd/mm/20 III CONSIDERATION FOR REWARD Provide any material information that may be relevant in light of the criteria for determining the amount of Reward or denial thereof. Include any supporting documents if necessary. IV DECLARATION BY INFORMANT I/we hereby declare that,- I/we have read and understood the Securities and Exchange Board of India (Prohibition of Insider Trading) Regulations, 2015; I/we accept that mere furnishing of information by me/us does not by itself confer on me/us right to get reward and that I/we may not get any Reward at all. I/we would be bound by the decisions that the authority competent to grant reward may take; I/we accept that the Securities and Exchange Board of India is under no obligation to pay any reward or enter into any correspondence regarding action or inaction taken as a result of this communication. I/we accept that the reward would be an ex-gratia payment which, subject to the Securities and Exchange Board of India Prohibition of Insider Trading) Regulations, 2015, shall be granted at the absolute discretion of the competent authority. The decision of the authority shall be acceptable to me/us and I/we shall not challenge it in any litigation, appeal, adjudication, etc. In the event of my/our death before the reward is paid to me/us, it may be paid to . (Details of nominee) I/we declare that the information contained herein is true, correct and complete to the best of my/our knowledge and belief and not obtained from the categories of persons indicated in sub-regulation (2) and sub-regulation (6) of regulation 7G of the Securities and Exchange Board of India (Prohibition of Insider Trading) Regulations, 2015 and agree to indemnify the Board in case it is not so found. I/we fully understand that I/we may be subject to action under securities laws as well as Section 182 of the Indian Penal Code, 1860 (45 of 1860) and ineligible for an Informant Reward if, in my/our submission of information or in any other dealings with the Board, I/we knowingly and wilfully make any false, fictitious, or fraudulent statements or representations, or use any false writing or document knowing that the writing or document contains any false, fictitious, or fraudulent statement. Signature: . Date: dd/mm/yy Place: V CERTIFICATE BY LEGAL REPRESENTATIVE (where applicable) I hereby certify as follows,- (a) I have reviewed the completed and signed claim form for completeness and accuracy and the information contained therein is true, correct and complete to the best of my knowledge; and (b) The declarant is the person who signed the original Voluntary Information Disclosure Form. Signature: . Date: dd/mm/yy Place: ] ************ NOTES:- 1. Inserted vide Notification No. SEBI/LAD-NRO/GN/2019/32 dated 17-09-2019