JEEVAN USHA BONDS

Application Form
Period 60 months :

Jeevan Associate Code

Office : Code ___________, Location _______________, State___________ ______________________________________________________________________________

To Manager (Bonds) Jeevansuraksha Capital Ltd. 91, Kunj Society, Alkapuri, Vadodara 390 007.

Dear Sir, I/We ___________________________________________ hereby agree that the terms and conditions mentioned in overleaf for conversion of Jeevan Usha bonds . Name of the Applicant Age Occupation Father / Husbands Name If applicant is minor ( Name of Guardian) Postal Address

Permanent Address Signature of the Applicant Bank Details Account Number Bank Name Branch Telephone First Nominee Name Relationship Age Percentage Second Nominee Name Relationship Age Percentage Signature of the Nominees : : (M) :

(1)_________________________(2)____________________________ Name of the Introducer & Code Signature Total Amount Cheque/DD/ Cash In words In Figure Date Bankers Name Branch Name

PAN Card No. If minor signature by Guardian ______________________________________________________________________________ DECLARATION Name (First no. holder) redeem bonds of I/We the amounting

_____________________________________________________, __________________________________ Rs.__________________________.

______________________________________________________________________________ Proof of Address : Driving License Electricity Bill Passport Ration Card Telephone Bill (BSNL/MTNL) Voter ID Card Or Any other ( Please give details) __________________________________________________________________________ Proof of Identity PAN Card Passport Driving License Voter ID Or Any other (Please give details) ______________________________________________________________________________ Signature of Applicant

TERMS & CONDITIONS

1. Bonds : (a) Applicant may apply for minimum 02 Bonds of Rs.6,000/- each and deposit Rs.200/- per month upto 60 months and in addition, applicant may deposit

Rs.100/-

per

month.

Any

such

deposit

may

be

made

on

weekly/monthly/quarterly/half yearly / yearly basis. (b) Company reserves right to reject any of the applications without assigning any reason/s whatsoever. (c) These bonds are not issued for the purpose of listing on any Stock Exchange. 1. Maturity Period : Maturity period of the bond is 60 months. 2. Mode of Payment : (a) All payments will be done by Cheque/Demand Draft/Cash to the Company against valid Receipt issued by the authorized official of the Company. In case of payment made otherwise then in any mode stated herein, the applicant will himself be solely responsible. (b) Payment above Rs. 20,000/- will be accepted only by Cheque/Demand draft. (c) Payment will be considered as duly received only after the cheque/demand draft is realized. (d) Outstation cheques will not be accepted in any circumstances 3. Options available to Bond Holders : (a) Bond holder may opt to convert the bond into 01 fully paid up equity share of Rs. 10 at a premium of Rs. 990 per share against the paid up value mentioned on the Bond. For this purpose, the Bond holder will require to communicate the option of conversion between the period of 59th to 60th month from the date of application along with necessary payment.

(b) Redemption :

(i)

The bond will be redeemed in full as per paid up value, on an application made by the Bond holder, as under expiry of 60 months from the date of application.

(ii) (iii)

Bond holder will not be able to get redemption of the bond if he has already opted for conversion. No interest will be payable for the period which pertains earlier or after the date of the bond.

Particulars Period in months Face Value of 02 Bonds Redemption on completion of 60 months

Redemption Amount (in Rs.) (a) 60 12000 Rs. 15,500

(c) For any reason, if Bond Holder fails to pay regular installments upto 60 months then that will be considered as partial payments and in such situation at the time of redemption, payments will be made as per the calculation charts / table available in the company and in such cases interest will be payable only maturity of the Bonds. consider pre-mature redemption under such circumstances. 4. Company will issue certificate of holding on demand by the bond holders and the on In the interest of Bond Holders, the company may

same will be sent to their address recorded with the company. 5. Nomination facility :

At the time of application for the bonds, the bond holders may nominate two persons along with share of the redemption amount payable to them.

6.

Dispute redressal/Arbitration Any dispute or difference arising relevant to the bonds, the same shall be settled through mutual discussion. In the event, the Parties fail to amicably settle such dispute or difference within 7 days of consultation, such dispute shall be resolved through arbitration. The venue of the arbitration shall be in the city of Vadodara. The arbitration proceedings shall be governed under the Arbitration and Conciliation Act, 1996. The arbitral Tribunal shall consist of a sole Arbitrator appointed with mutual consent by both the parties. The award

of the Arbitrator shall be a reasoned award and shall be final and binding on the Parties. The Arbitration shall be conducted and the award shall be rendered in English language. The Civil Courts at Vadodara shall have exclusive jurisdiction in respect to try and entertain any proceeding arising under or out of this Agreement. The laws of Republic of India shall govern this Agreement.

GENERAL RULES

(a)

Company may amend / modify any of the terms and conditions governing the Bonds in future from time to time for any reason including changes as may be notified by the Regulatory Authorities. amendment/s Company will make any such by display on the Notice Board of the company or by

publication in the newspaper having circulation in the area where the Registered Office of the company is situated or by any other means of electronic communication etc. (b) Company reserves the right to redeem the Bond company will be binding to all the bond holders. (c) In case of the signatures by thumb impression, the same will have to be authorized by the authorized employee of the company or Manager of a Nationalised Bank or Magistrate or Notary Public. (d) Company will be free to issue other types of Bonds, to raise funds by any other means including loans, without taking concurrence/consent of the Bondholders. (e) (f) Register of Bondholders will be maintained as per provisions of Companies Act, 1956. Any type of communication / instructions will be given to the bondholders as per the address recorded in the Register of the company by way of Ordinary Post / Courier. pre-maturely without

assigning any reason/s whatsoever and in such event this decision of the

(g) (h)

Any individual / Karta of the HUF or a company who has association with any of the company can apply for the Bonds. Date of realization of Cheque / Demand Draft will be considered as the date of application.

(i)

Applicant will be solely responsible for the contents filled in by him in the application forms including that of signature and sources of fund.

(j)

Payments will be made as per Income Tax Rules. Applicant will be required to produce copy of PAN Card in case of investment of Rs.800/- or more per month. In case applicant desires to have exemption from Tax, he will have to lodge necessary declaration/certificate in the prescribed forms to the company every year. Prescribed forms for this purpose are available from the company.

(k)

Under the order of appropriate Court, company reserves right to transfer bonds to other company for its payment in case of merger, demerger, amalgamation or any kind of arrangement leading to restructuring with other company. In such situation the Bonds will be considered as if they have been issued by the original company. This kind of instruction / communication will be displayed on the Notice Board of the company or will be published in the News papers where Registered Office of the company is situated.

DECLARATION I / We,________________________________________________ with this application hereby request and apply to the company to issue me optionally fully convertible unsecured bonds equivalent to the payments being made by me. I/We, _________________________________________________ hereby give my consent to abide all the provisions of Memorandum & Articles of Association of the company as well as all the terms, conditions and rules mentioned in this application forms and any amendments as may be notified by the company from time to time. I/We, __________________________________________________ hereby authorize you to enter my name as a bondholder in the Register of bondholders maintained by your company and in the event of exercising the option, I/We ________________________________ authorize you to enter my name in the Register as

may be maintained by the company, after the bonds are converted into equity shares and that such shares are allotted to me. I/We __________________________________ authorize you and give consent that as per Clause 8(k), will act as per the situation mentioned therein. I/We __________________________________ declare that I am Indian Resident and I am not nominating any person as nominee who is resident outside India. I/We __________________________________ confirm that I/We ____________________ are associated / related with Jeevansuraksha group. I/We __________________________________ confirm that all the terms and conditions given in this application form are understood by me in my language mother tongue and that I/We __________________________________ agree with the same. __________________________________ Signature of the Applicant (In case of minor, signature by the Guardian)

DECLARATION I/We __________________________________ as a representative of the applicant hereby confirm that I have explained all the terms and conditions of every columns of this application form to the applicant in the vernacular language/his mother tounge which he understands. I/We __________________________________ confirm and declare that all the information / declaration given by the applicant or by the undersigned are true and bonafied to the best of my information and knowledge. _______________________________________ Signature of Jeevan Associate