Date Securities Depository Center Messrs Securities Depository Center Please issue a notice of my securities balances as of Language of the Notice Arabic English أرصدة ملكيتي Ownership balance for all securities with all members Ownership balance for all securities with a specific member Member Type Broker Custodian Central Registry Broker/Custodian's Name Account No. أرصدة ملكيتي لورقة مالية محددة لدى كافة الأعضاء Ownership balance of a specific security with all members - Select -StocksBondsSubscription rightsIslamic bonds Security Name Security No. Ownership balance for a specific security with a specific member Security Type Broker Custodian Central Registry Broker/Custodian's Name Account No. with Member Issuer's Name Security Type - Select -StocksBondsSubscription rightsIslamic bonds Security No. Investor's Information Name of the Securities' Owner SDC No. Name of Authorized Signatory for Judicial Entities Signature Official Stamp for Judicial Entities Agency Information Agency Type Caretaker Custodian Agent Trustee Receiver Guardian Liquidator Other Agent's Name SDC No. Nationality Signature I, the signatory above, acknowledge that the data and information stated above are correct, accurate and complete and I assume the full responsibility arising therefrom without holding the Securities Depository Center responsible for the invalidity, inaccuracy and/or incompleteness of the said data and information. Statement's Reception Information Name of Statement(s) Receiver Date Signature For Securities Depository Center's Use For Securities Depository Center's Use Operation Name Signature Date Entry Name Signature Date Audit Name Signature Date Approval Name Signature Date Signed Before Name Signature Date Important Notice:All information and data should be filled accurately and clearly. In cases where there is an agent, the power of attorney issued by the competent authorities shall be attached, and if it is issued outside the Kingdom, it shall be duly certified. The following valid identification documents must be attached to this form:Natural Persons:- For Jordanians: Passport or Identity Card issued by the Civil Status and Passport Department, provided that it contains the National Number.- For Non-Jordanians: Passport.Judicial Entities:- For Jordanians: Registration Certificate at the official competent authorities.- For non-Jordanians: Certificate of registration, duly certified. Required documents Please attach Required documents One file only.300 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. CAPTCHA Get new captcha! What code is in the image? Enter the characters shown in the image. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
