SCHEDULE D
[See regulation 7B]
Form for Informant’s Voluntary Information Disclosure to be submitted to the Board.
Note: For submission of information through a legal representative, the redacted copy of the Form expunging information that may identify the Informant shall be submitted by the legal representative without expunging any information relating to the legal representative and the details relating to the violation of securities laws.
*Indicates that the required field is non-mandatorily, remaining fields are mandatory
| I. PERSONAL INFORMATION OF THE INFORMANT | ||
| A.INDIVIDUAL 1: Last Name:……………… | First Name:……………… | Title:……………… |
| Address: | City / State: | PIN: |
| Telephone (with State Code): | Mobile: | E-Mail address: |
| Employment Details*: | Permanent Account Number, if available: |
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| II. LEGAL REPRESENTATIVE (where applicable) |
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| Last Name:……………… | First Name:……………… | Title:……………… |
| Firm Name (if not self-employed): | ||
| Contact address : | City / State: | PIN: |
| Residence address: | City / State: | PIN: |
| Telephone (with State Code): | Mobile: | E-Mail address: |
| Bar Council Enrolment Number: | ||
| III SUBMISSION OF ORIGINAL INFORMATION | ||
| 1. Is it a violation of securities laws? Yes / No | ||
| 2. If yes to question (1), please describe the type of violation: | ||
| 3. Has the violation: Occurred / Occurring / Potential to occur in future | ||
| 4. If the violation has occurred, date of occurrence: dd/mm/yy (in case exact date is not known, an approximate period may be entered) | ||
| 5. Have the individual(s) or their representatives had any prior communication(s) or representations with the Board concerning this matter? Yes (Details thereof) / No | ||
| 6. Does this violation relate to an entity of which the individual is or was an officer, director, counsel, employee, consultant or contractor? Yes (Details thereof) / No | ||
| 7. If yes to question (6), was the original information submitted first to your Head or internal legal and compliance office? Yes / No | ||
| 8. If yes question (7), then please provide, Date of submission of original information: dd/mm/yy | ||
| 9.* Please describe in detail how the information submitted by you constitutes a violation of insider trading laws. The details must include specific information with respect to: i. details of the securities in which insider trading is alleged; ii. the unpublished price sensitive information based on which insider trading is alleged; iii. date on which the unpublished price sensitive information was made public; iv. details of circumstances/evidence leading to possession of unpublished price sensitive information by the alleged violator(s); v. details of insiders/suspects and their trades (i.e. purchase/sale and quantity purchased/sold) along with dates/period of trades. *Substituted vide SEBI (Prohibition of Insider Trading) (Second Amendment) Regulations, 2020 dated 29.10.2020. To view the notification, Click Here |
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| 10. What facts or supporting material is your allegation based on? *Please include self-certified copies of all the relevant documents. Please attach any additional documents to this form, if necessary. *Inserted vide SEBI (Prohibition of Insider Trading) (Second Amendment) Regulations, 2020 dated 29.10.2020. To view the notification, Click Here |
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| 11. Identify any documents or other information in your submission that you believe could reasonably be expected to reveal your identity and explain the basis for your belief that your identity would be revealed if the documents were disclosed to a third party | ||
| 12. Provide details of connection amongst the Informant, the company whose securities are involved and the person against whom information is being provided: | ||
| IV. DECLARATION |
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| I/we hereby declare that,- A. I/we have read and understood the Securities and Exchange Board of India (Prohibition of Insider Trading) Regulations, 2015; B. 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; C. I/we accept that the Securities and Exchange Board of India is under no obligation to enter into any correspondence regarding action or inaction taken as a result of my/our information. D. 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. E. In the event of my/our death before the reward us paid to me/us, it may be paid to …………. (Details of nominee) F. 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 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: |
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Substituted vide SEBI (Prohibition of Insider Trading) (Second Amendment) Regulations, 2020 dated 29.10.2020. To view the notification, Click Here