To be printed on Rs.

500/- stamp paper

DECLARATION CUM INDEMNITY

THIS DECLARATION CUM INDEMNITY IS EXECUTED ON THIS _____ DAY OF ______, 2017 BY :

_______________________, son of______________, age _______________a Proprietor/Partner/Authorised

Representative of ________________, having its Office/Registered office
a____________________________________________, (hereinafter referred to as "the Executant") in favour of
Reliance ________________ having its registered office at ______________________ (“hereinafter referred to as
“the Company”)

WHEREAS:

A. The Executant has entered into a ___________________ Agreement dated _________ ["said
Agreement"] with the Company, whereby the Company has appointed the Executant to distribute,
market, promote, sale, etc. the products and services of the Company within the __________
Territory, upon such terms and conditions as specifically mentioned in the said Agreement.

B. The Executant during the course of business has purchased from the Company Prepaid Printed
Recharge Voucher and /or the E-recharge Vouchers /talk time to be sold, distribute it further ,
directly and/or indirectly by the Executant to retailers, end subscribers (hereinafter collectively
referred to as “RVs”) from time to time for sale and onward distribution as per the terms and
conditions of the said Agreement.

C. The Executant has in its knowledge that and confirmed that , the said Agreement is terminated
on __________ due to the Company's closure of wireless business and thereby, the Executant shall
not further sell or distribute with effect from __________ and has to surrender the unutilized /
unsold said RVs purchased from the Company to arrive at the full and final payment under the
said Agreement.
D. The Executant declares that the unutilized / unsold RVs purchased from the Company as
provided in Annexure A herein has been surrendered and there are no RVs other than those
mentioned in Annexure A available or further sold to any third party.
E. The Executant understands that use / selling of any RVs post termination may result in claims
and / or penalty from third parties including without limitations TRAI, retailer and/or any third
party/ies and the Executant undertakes that it has taken all necessary steps to collect and
surrender the RVs to the Company and any failure to surrender the RVs resulting in claims in any
nature whatsoever from third parties shall be to the account of the Executant.
F. The Executant further declares and undertakes that it has not withheld or caused to withhold
any RVs.
 G. On the aforesaid declaration and undertaking given by the Executant, the Company has agreed
to process the full and final settlement of the Executant on execution of this Declaration cum
Indemnity.

IN VIEW OF THE AFORESAID DECLARATION AND UNDERTAKINGS, THE EXECUTANT HEREIN DO

HEREBY SOLEMNLY AFFIRM, DECLARE & INDEMNIFY THE COMPANY AS UNDER:

1. That the Executant shall indemnify and keep the Company and its subsidiary/s, its Group
Companies, affiliates, successors, assigns or its authorized representative indemnified for any and/or
all acts, deeds, commissions and omissions which may result into any and/or all kind of loss(es),
damage(s), unwarranted consequences of any nature whatsoever and from any corner whatsoever to
Company on account of any PRs which are withheld / not collected / not surrendered .

2. That the Executant understands that the Company will be releasing the full and final amount on
the aforesaid declaration given by the Executant and that the Executant including its retailers,
resellers, subscribers or third party shall not have any claims against the Company pertaining to PRs
which are not surrendered by the Executant. The Executant do hereby indemnify and keep
indemnified and harmless Company it's subsidiary/s, its group companies, affiliates, successors,
assigns or its authorized representative against all claims, demands, actions, proceedings, loss,
damages, cost, charges and expenses which may be made against or commenced against Company it's
subsidiary/s, its group companies, affiliates, successors, assigns or its authorized representatives by
any third party including without limitations the Distributor, retailer, reseller, subscriber etc., or
which Company may or may have to incur or suffer on account of the non-surrendered PRs.

3. The Executant herein declare and confirm that the Company that it shall not have any future claim
with respect to the payment made by the Company with respect to the said unutilized/unsold PRs
surrendered by the Executant. The Executant herein further declare and confirm that execution of this
Declaration cum Indemnity shall mean full compliance and discharge of the terms, conditions and
obligations of the said Agreement by the Company.

4. The Executant do hereby further declare that this Declaration cum Indemnity is executed by us on
our own free will and without any undue influence or coercion by any other party.

EXECUTANTS :

NAME/SIGN/ADDRESS of EXECUTANT

WITNESSES :

1. Name : __________________________

Son of ___________________________
 R/O : ____________________________

2. Name : __________________________

Son of ___________________________

R/O : ____________________________

(this document has to be notorised)