CHILDREN WHOLE LIFE INCOME SCHEME

Private Placement of Children Whole Life Income Scheme Bonds in the nature of Secured Redeemable Non Convertible Debentures (NCD’s) aggregating Rs. 10 Crores.

No. of NCBs applied for________________(In words____________________________________ Amount Rupees___________________(Rupees_________________________________________ ___________________________________________________________________________Cash/ Cheque / DD No._______________________ dated___________drawn on____________________

Applications must be made for a minimum of one Bond and in multiples of one thereof.

1. CHILD’s NAME IN FULL ___________________________________________(SOLE/FIRST) Father’s Name__________________________________________Age_________________________ Address________________________________________________City_________________________ Pin____________Tel No.____________________________DOB______________________________

SCHEME A – Rs. 2,380.00 PER MONTH PER BOND I hereby undertake that I am fully responsible to deposit Rs. 2,380.00 per month / per bond and if I fail to deposit the same due to any reason, the society has full right to cancel the allotment of Bond and refund my deposit with out Interest after adjusting the penalty of Rs. 5,000/- per Bond and Date of Birth shown above is correct. Signature ___________________________________ Date__________________________