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[ To be executed on Rs.100/- Non
  Judicial stamp paper] 
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<    > equity shares
  having distinctive numbers from < > to < > of the face  
value of Rs.<
  >/- (Rupees <  > only) stand  registered in the name of the Late name of the deceased> in the books of
  THE company <         >, late
  <name of the deceased>  who died
  on <date> leaving behind him the following 
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Sl. no 
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NAME 
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AGE 
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RELATION 
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The above mentioned shares / debentures were the separate and
  self-acquired property of the deceased. Under the Hindu Succession Act, 1956,
  the persons mentioned above his only heirs are entitled to inherit the
  aforesaid shares /  
debentures 
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I therefore, request the company to transmit these aforesaid shares
  /debentures stand registered in the name of the Late <           >, in my name and also to pay
  me dividend payable by the company without production of succession
  certificate or letters of administration or probate. 
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In consideration of
  the above having agreed to comply with my request on my executing a bond in
  favour of the company, I, the applicant, hereunder for myself, my heirs,
  executors, administrators and assigns to hereby jointly and  severally covenant with the company, its
  successors and assigns that we and each of our heirs, executors,
  administrators and assigns will, on the company transferring the said shares
  / debentures into my name and paying to me the dividends already due, at all
  times save, defend and keep indemnified the company its successors and
  assigns, its estate and effects, and the directors, manager, company
  secretary and shareholders of the company, their heirs, executors and assigns
  from and against all actions, causes of actions, suits, proceedings,
  accounts, claims and demands whatsoever for or on account of the said shares
  / debentures of the dividends of any part thereof, or otherwise in connection
  with the same and from and against all claims, damages, costs, charges, expenses
  and losses arising in any manner howsoever. 
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In witness whereof,
  I, the applicant herein have signed and set my hand on <    > 
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( Signature of
  Claimant(s)) 
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Witness-1 
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Address 
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Witness-2 
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We, the undersigned,
  certify that the above facts are true and bind ourselves as sureties to make
  good all claims, charges, costs, damages, demands, expenses and losses which
  the said company may sustain, incur or become liable for in consequence of
  claims, charges, costs, damages, demands, expenses and losses from our
  persons or our Properties, as the
  case may be. 
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Witness-1 
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(Signature of Surety) 
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Witness-2 
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