AFFDAVIT CUM INDEMNITY BOND

[in case of loss of original scheme certificate]

I, S. KALA w/o T.P. SUBRAMANIAN Residing at No.31, Abirami Nilayam, Green

Garden Layout Shirdi Sai Nagar, Munniyakolala, Marathahalli Bangalore-560037.
jontly and severally state on solemnly affirmation as under

I say that I S. KALA working in M/S INDIAN MINI DRILLS PVT LTD and holding
pension fund KN/KRP/5318/209 with the regional provident fund commissioner
Bangalore. Scheme Certificate No. 5762. Dated:- 8-11-2006.

2. I say that the said member was issued a scheme certificate under para 12[8] of
Employees pension schem 1995 after exit from the above stated establishment.

3. I say that the above stated scheme certificate has been lost irretrievably
misplaced.

4. I state that if above stated original scheme certificate is found at a later date it
will not be utilized and shall be surrendered to the office of the Employees
provident fund organization.

5. I further indemnity the central Board of Trustees Employees provident fund

and keep them indemnified against any loss that it my incur in future by was of
indemnified against any loss that it my incur in future by was of indemnified
granting pension against the above stated original scheme certificate reported to
have been lost misplaced.

The affidavit cum indemnity bond have executed by means and I do stated that
the facts mentioned herein before are true and correct be the best of my
knowledge and belief.

Solemnly affirm at Bangalroe

This day of 28-08-2012

Signature of Two sureties DEPONENT

With name and address 1.

2.

Identified and

Explained by me.