This is not a mandatory field.

It is only to be completed if you have been specifically issued in advance with a Provider Reference by deListed.

This is a mandatory field.

Please provide the full and exact name(s) and address of the Custodian in whose name the securities are registered. If in doubt consult your adviser or platform provider. Do not enter details to this web page if the securities are held in the name of the beneficial owner.

This is a mandatory field.

Please provide the full and exact name (as per the account with the Wrap Provider) of the beneficial owner(s). If the name occupies more than one line, please "click to add a row for each line".

Do not provide the address here, that is entered in the next field.

This is a mandatory field.

Please provide the full and exact address (as per the account with the Wrap Provider) of the beneficial owner(s). If the address occupies more than one line, please "click to add a row for each line".

Do not provide the name here, that is entered in the field above.

This is a mandatory field.

Please provide the full and exact name(s) and address of the Wrap Provider on whose platform the securities are held. If in doubt consult your financial adviser.

This is a mandatory field.

Please refer to your Holding Statement or other document to ascertain your Wrap Account Number.

This is a mandatory field.

Please provide the full and exact name(s) and address of your Financial Adviser.

If you are the Beneficial Owner, you do not have a Financial Adviser and you have sole authority to dispose of the securities, please enter "None" to this field.

This is a mandatory field.

Please provide the full and exact name of the failed company in which you hold the worthless shares.

This is not a mandatory field.

but we would prefer that you provide the exact ASX code of the failed company in which you hold the worthless shares

This is a mandatory field.

Please provide the number of shares as a figure with no commas, no spaces eg 10000 Take this from your Holding or Dividend Statement.

This is a mandatory field.

Please provide the number of shares in words eg Ten thousand.

This is not mandatory field.

Please do not enter anything to this field unless you are selling securities other than Ordinary Fully Paid Shares in which case provide precise details of the security you are selling eg 7.75% RESET CONVERTIBLE NON-CUM. PREFERENCE SHARES.

This is not mandatory field.

Please provide the Shareholder Reference Number (SRN) if this holding is issuer sponsored. Take this from your Holding or Dividend Statement. If your shares are certificated enter as Cert No: ????????? (enter the actual certificate number in place of the question marks).

This is a mandatory field if a SRN is not provided.

Please provide the Holder Identification Number (HIN) if this holding is broker sponsored. Take this from your Holding or Dividend Statement. If you do not have access to either a SRN or HIN for this holding enter "Custodian to provide".

This is a mandatory field if a HIN is provided.

Please provide the full and exact name and address of your broker firm if this holding is broker sponsored.

If you do not know the name of the broker and you have completed the HIN field enter "Custodian to provide"

This is a mandatory field.

Please enter your name, status (just enter Owner, or Adviser or Wrap Provider depending on which of them you are) and address. (While documents will be addressed to the beneficial owner, they will be emailed to the email address you provide in the next field.)

This is a mandatory field.

Please provide your exact email address (check it once you have entered it) as this serves as our primary point of contact if we require clarification of details provided by you.

This is not a mandatory field.

Please provide your telephone number as this serves as a secondary point of contact if we require clarification of details provided by you.