common application form application no. for...

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COMMON APPLICATION FORMFOR LUMP SUM/SYSTEMATIC INVESTMENTS

Application No.

Investor must read Key Scheme Features and Instructions before completing this form. All sections to be completed in ENGLISH in BLACK / BLUE COLOURED INK and in BLOCK LETTERS.

I confirm that I am a First time investor across Mutual Funds.(Rs. 150 deductible as Transaction Charge and payable to the Distributor)

I confirm that I am an existing investor in Mutual Funds.(Rs. 100 deductible as Transaction Charge and payable to the Distributor)

TRANSACTION CHARGES FOR APPLICANTS THROUGH DISTRIBUTORS ONLY [Refer Instruction XII and please tick () any one]

In case the purchase / subscription amount is Rs. 10,000 or more and your Distributor has opted to receive Transaction Charges, the same are deductible as applicable from the purchase/subscriptionamount and payable to the Distributor. Units will be issued against the balance amount invested.Upfront commission shall be paid directly by the investor to the AMFI registered Distributors based on the investors’ assessment of various factors including the service rendered by the distributor.

1 EXISTING UNITHOLDERS INFORMATION If you have an existing folio no. with PAN & KYC validation, please mention your name & folio No. and proceed to Step 4

Name FIRST MIDDLE LASTMr. Ms. M/s

2 APPLICANT(S) DETAILS (Please Refer to Instruction No. II (b) )

Enclosed (Please )§ KYC Acknowledgement Letter

Date of Birth**

Name of * # GUARDIAN IN CASE FIRST APPLICANT IS A MINOR OR CONTACT PERSON IN CASE OF NON-INDIVIDUAL APPLICANTS

Enclosed (Please )§ KYC Acknowledgement Letter

D D M M Y Y Y Y

PAN*

PAN*

Sole/FirstApplicant

Mr. Ms. M/s FIRST MIDDLE LAST

Mr. Ms.

Relationship withMinor applicant

Natural guardian Court appointed guardian

Mandatory information – If left blank the application is liable to be rejected.

BROKER CODE (ARN CODE)SERIAL NUMBER, DATE & TIME OF RECEIPT

FOR OFFICIAL USE ONLYSUB-BROKER ARN CODE Employee UniqueIdentification No. (EUIN)

SUB-BROKER CODE(As allotted by ARN holder)

Declaration for "execution-only" transaction (only where EUIN box is left blank) (Refer Instruction No. XIII)I/We hereby confirm that the EUIN box has been intentionally left blank by me/us as this is an “execution-only” transaction without any interaction or adviceby the employee/relationship manager/sales person of the above distributor or notwithstanding the advice of in-appropriateness, if any, provided by theemployee/relationship manager/sales person of the distributor and the distributor has not charged any advisory fees on this transaction.

SIGNATURE OF SOLE / FIRST APPLICANT SIGNATURE OF SECOND APPLICANT SIGNATURE OF THIRD APPLICANT

FOLIO No.

ARN- E

3 KYC DETAILS (Mandatory)

3a. Status of Sole/1st Applicant [Please tick ()] Indian Resident Individual On behalf of Minor NRI (Repatriable) NRI (Non-Repatriable) On behalf of NRI - Minor (Repatriable) On behalf of NRI - Minor (Non-Repatriable) Sole Proprietorship HUF - Indian HUF - NRI Partnership Firm Limited Partnership (LLP) Listed Company Unlisted Company Body Corporate Bank / FI Insurance Company Government Body AOP/BOI Trust/Society Provident Fund Superannuation / Pension Fund Gratuity Fund FOF

- MF Schemes FII Private Limited Company Non Government Organisation People of Indian Origin Foreign Portfolio Investor Defense Establishment NPS Trust

Global Development Network Foreign National ___________________ [Please specify category] Others _______________________________________ (Please specify)

a. Occupation Details [Please tick ()] Private Sector Service Public Sector Service Government Service Business Professional Agriculturist Retired Housewife Student Forex Dealer Others ______________________________________________________________ (Please specify)

b. Gross Annual Income (in Rupees) [Please tick ()] Below 1 Lac 1-5 Lacs 5-10 Lacs 10-25 Lacs >25 Lacs-1 crore >1 crore OR Net worth ̀̀̀̀̀ _____________________

c. Others [Please tick ()] Politically Exposed Person (PEP) Related to a Politically Exposed Person (RPEP) Not Applicable

3c. Gross Annual Income (in Rupees) [Please tick ()] Below 1 Lac 1-5 Lacs 5-10 Lacs 10-25 Lacs >25 Lacs-1 crore >1 croreNet-worth in (Mandatory for Non-Individuals) `̀̀̀̀ ___________________________________ as on (Not older than 1 year)D D / M M / Y Y Y Y

3d. For Individuals [Please tick ()] I am Politically Exposed Person (PEP)^ I am Related to Politically Exposed Person (RPEP) Not applicable

4 JOINT APPLICANTS, IF ANY AND THEIR DETAILSMode of Holding [Please tick ()] Joint (Default) Anyone or Survivor

2nd Applicant Name (Should match with PAN Card) PAN (2nd Applicant)

3b. Occupation Details [Please tick ()] Private Sector Service Public Sector Service Government Service Business Professional Agriculturist Retired Housewife Student Forex Dealer Others ______________________________________________________________ (Please specify)

a. Occupation Details [Please tick ()] Private Sector Service Public Sector Service Government Service Business Professional Agriculturist Retired Housewife Student Forex Dealer Others ______________________________________________________________ (Please specify)

b. Gross Annual Income (in Rupees) [Please tick ()] Below 1 Lac 1-5 Lacs 5-10 Lacs 10-25 Lacs >25 Lacs-1 crore >1 crore OR Net worth ̀̀̀̀̀ _____________________

c. Others [Please tick ()] Politically Exposed Person (PEP) Related to a Politically Exposed Person (RPEP) Not Applicable

3rd Applicant Name (Should match with PAN Card) PAN (3rd Applicant)

KYC Proof Attached (Mandatory)

KYC Proof Attached (Mandatory)

3e. Any other information:

5 Power of Attorney (PoA) Holder Details:Name of PoA Mr. Ms. M/s. (Should match with PAN Card) PAN (PoA Holder) KYC Proof Attached (Mandatory)

For Non-Individual Investors (Please attach mandatory Ultimate Beneficial Ownership (UBO) declaration form -Refer instruction no. XX)i. Foreign Exchange / Money Changer Services YES NOii. Gaming / Gambling / Lottery / Casino Services YES NOiii. Money Lending / Pawning YES NO

^Politically Exposed Persons (PEP) are individuals who are or have been entrusted with prominent public functions in a foreign country, e.g., Heads of States or of Governments, senior politicians, seniorgovernment/judicial/military officers, senior executives of state-owned corporations, important political party officials, etc"PEP/RPEP information is also applicable for authorised signatories/Promoters/Karta/Trustee/Whole Time Directors/etc.

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Correspondence Address (Please provide full address)*

HOUSE / FLAT NO.

STREET ADDRESS

STREET ADDRESS

COUNTRY PIN CODE

Overseas Address (Mandatory for NRI / FII Applicants)

HOUSE / FLAT NO.

STREET ADDRESS

STREET ADDRESS

PIN CODE

Please � if you wish to receive Account statement / Annual Report/ Other statutory information via Post instead of Email

CITY / TOWN STATE

COUNTRY

CITY / TOWN STATE

Please � any of the frequencies to receive Account Statement through e-mail £ : Daily Weekly Monthly Quarterly Half Yearly Annually

Tel. (Res.)

Mobile

FaxTel. (Off.)

Email £

* Mandatory information – If left blank the application is liable to be rejected.** Mandatory in case the Sole/First applicant is minor.§ For KYC requirements, please refer to the instruction Nos. II b(5) & X

MA

ND

ATO

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7 BANK ACCOUNT (PAY-OUT) DETAILS OF SOLE/FIRST APPLICANT (Please Refer to Instruction No. III)

Name of Bank

Account NumberAccount Type NRE NRO Savings Current FCNR

Branch Name

9 Digit MICR code 11 Digit IFSC Code

Branch City

Mandatory information – If left blank the application is liable to be rejected. (Mandatory to attach proof, in case the pay-out bank account is different from the source bank

account.) For unit holders opting to hold units in demat form, please ensure that the bank account linked with the demat account is mentioned here.

# Name of Guardian/Contact Person is Mandatory in case of Minor/Non-Individual Investor.For documents to be submitted on behalf of minor folio refer instruction II-b(2)£ Please refer to instruction no. IX

Enclosed (Please �):

Bank Account Details Proof Provided.

6 Correspondence Details of Sole/First Applicant:

Micro Investment upto Rs. 50,000/- (Please �) Mandatory. [Please refer instruction No. IV(d)]

Sole/First

Applicant

2nd Applicant

3rd Applicant

8 INVESTMENT & PAYMENT DETAILS (Refer Instruction No. IV) For Plans & Sub-options please see key features for scheme specific details

Name of scheme ICICI PRUDENTIAL

Option & Sub option (Please � the appropriate boxes only if applicable to the scheme in which you plan to invest)

PAN Exempt KYC Reference No. (PEKRN) (Mandatory if PAN not provided)



SUB-OPTION: Divident Reinvestment Dividend Payout

Dividend Frequency:

OPTION: Growth/Cumulative Dividend Bonus^PLAN:

Regular DirectOR AEP– Regular@ OR Appreciation

^Bonus Option, refer instruction no. IV(h) @Cumulative – AEP Regular Option: Encashment of units is subject to declaration of dividend in the respective Scheme(s). Please refer to Instruction no. IV(g)

AEP Frequency:

SIP Through ECS/Standing Instruction / Direct Debit PDCs ¶ SIP Frequency* Monthly Quarterly

Subsequent SIP Installment Details

12 / 2016 12 / 2018 Or other please

12 / 2023 12 / 2099 fill in alongside

PER CHEQUE`Amount InvestedFrom Cheque No. To Cheque No.

No. of Cheques Drawn on BANK / BRANCH

Please � applicable check boxes. ¶ PDCs - Post Dated Cheques *Default SIP Frequency is Monthly.

M M Y Y Y YM M Y Y Y Y

Applications with Third Party Cheques, prefunded instruments etc. and in circumstances as detailed in AMFI Circular No.135/BP/16/10-11 shall be processed in accordance with the said

circular. Please read the instruction no. VI(e). Third Party Payment Declaration form is available in www.icicipruamc.com or ICICI Prudential Mutual Fund branch offices.

Account Type NRE NRO Savings Current FCNR

Payment details for Lump Sum Investment/details of

first cheque for SIP payment through PDCs

B`DD Charges

(if applicable)A + B`

Amount

Invested

Mode of Payment Cheque DD Funds Transfer NEFT RTGS

Cheque /

DD NumberD D M M Y YDate

Amount PaidA`

Bank Name

AccountNumber

Bank Branch & City

SIP Date 7th 10th 15th 25th

Start Month/Year End Date

9 DEMAT ACCOUNT DETAILS (Optional - Please refer Instruction No. XI)

If yes, Depository Participant (DP) ID (NSDL only) Beneficiary Account Number (NSDL only) If yes, Depository Participant (DP) ID (CDSL only)

Do you want units in demat form : Yes OR No (Please �)The application form should mandatorily accompany the latest Client investor

master/ Demat account statement.

NSDL OR CDSL (Please �)

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11 INVESTOR(S) DECLARATION & SIGNATURE(S)


The Trustee, ICICI Prudential Mutual Fund, I/We have read and understood the Scheme Information Document/Key Information Memorandum of the Scheme(s). I/We apply for the units of the Fund and agree to abide bythe terms, conditions, rules and regulations of the scheme and other statutory requirements of SEBI, AMFI, Prevention of Money Laundering Act, 2002 and such other regulations as may be applicable from time to time.I/We confirm to have understood the investment objectives, investment pattern, and risk factors applicable to Plans/Options under the Scheme(s). I/we have not received nor been induced by any rebate or gifts, directlyor indirectly, in making this investment. I/We declare that the amount invested in the Scheme is through legitimate sources only and is not designed for the purpose of contravention or evasion of any Act, Regulations orany other applicable laws enacted by the Government of India or any Statutory Authority. I/We agree that in case my/our investment in the Scheme is equal to or more than 25% of the corpus of the plan, then ICICI PrudentialAsset Management Co. Ltd.(the 'AMC'), has full right to refund the excess to me/us to bring my/our investment below 25%. I/We hereby declare that I am/we are not US Person(s). I/We hereby declare that I/we do nothave any existing Micro SIPs which together with the current application will result in a total investments exceeding Rs.50,000 in a year. The ARN holder has disclosed to me/us all the commissions (in the form of trailcommission or any other mode), payable to him for the different competing Schemes of various Mutual Funds from amongst which the Scheme is being recommended to me/us. I/We interested in receiving promotionalmaterial from the AMC via mail, SMS, telecall, etc. If you do not wish to receive, please call on tollfree no. 1800 222 999 (MTNL/BSNL) or 1800 200 6666 (Others).

10 NOMINATION DETAILS (Refer instruction VII)

Nominee

Guardian

Nominee’s

Address

(Mandatory)

SIGNATURE OF NOMINEE / GUARDIAN, IF NOMINEE

IS A MINOR

HOUSE / FLAT NO STREET ADDRESS

Date of BirthNAME OF NOMINEE

MANDATORY, IF NOMINEE IS A MINOR

CITY / TOWN PIN CODE

(Mandatory if nominee is minor)

Relationship with the Nominee: Father Mother Legal Guardian [Please tick (�)]

D D M M Y Y

I/We hereby nominate the undermentioned nominee to receive the amount to my/our credit in event of my/our death.

Scheme

From Cheque/DD No.

From Date

TOTAL AMOUNTICICI PRUDENTIAL

M M Y Y

To Cheque/DD No.

AMOUNT PER CHEQUE

BANK AND BRANCH

` `SCHEME AND OPTION

End Date 12 / 2016 12 / 2018 12 / 2023 12 / 2099 Other (Specify)Y Y M M Y YY Y

EXISTING FOLIO NO.

ACKNOWLEDGEMENT SLIP (Please Retain this Slip)

To be filled in by the Investor. Subject to realization of cheque and furnishing of Mandatory Information.

FOR ANY ASSISTANCE OR FURTHER INFORMATION PLEASE CONTACT US

ICICI Prudential Asset Management Company Limited3rd Floor, Hallmark Business Plaza, Sant Dyaneshwar Marg, Bandra (East), Mumbai - 400 051. India

SIGNATURE, STAMP & DATE

TOLL FREE NUMBER 1800 222 999 (MTNL/BSNL) 1800 200 6666 (OTHERS) EMAIL [email protected] WEBSITE www.icicipruamc.comNote: All future communications in connection with this application should be addressed to the nearest ICICI Prudential Mutual Fund Customer Service Centre, quoting full name ofthe first applicant, the application serial number, the name of the scheme, the amount invested, date and the place of the Customer Service Centre where application was lodged.

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Application No.

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Depository Participant (DP) ID (NSDL only) Beneficiary Account Number (NSDL only) Depository Participant (DP) ID (CDSL only)

Do you want units in demat form : Yes OR No (Please �) The application form should mandatorily accompany the latest Client investor master/ Demat account statement.

SIGNATURE(S) OF BANK ACCOUNT HOLDER(S) AS IN BANK RECORDS (Mandatory)

I/We have read and understood the contents of the Scheme Information Document(s) and Statement of Additional Information and the terms & conditions of SIP enrolment and ECS (Debit Clearing) / Direct Debit/ Standing Instructionand agree to abide by the same. I /We hereby apply to the Trustee of ICICI Prudential Mutual Fund for enrolment under the SIP of the following Scheme(s)/ Plan(s) / Option(s) and agree to abide by the terms and conditions of thesame. I/We hereby declare that the particulars given above are correct and express my willingness to make payments referred above through participation in ECS. This is to inform I/we have registered for the RBI's Electronic ClearingService (Debit Clearing) and that my payment towards my investment in ICICI Prudential Mutual Fund shall be made from my/our below mentioned bank account with your bank. I/We authorise the representative carrying this ECSmandate Form to get it verified & executed. I/We authorise the bank to honour the instructions as mentioned in the application form. I/We also hereby authorise bank to debit charges towards verification of this mandate, if any.I/We agree that AMC/Mutual Fund (including its affiliates), and any of its officers directors, personnel and employees, shall not be held responsible for any delay/wrong debits on the part of the bank for executing the direct debitinstructions of additional sum on a specified date from my account. If the transaction is delayed or not effected at all for reasons of incomplete or incorrect information, I/We would not hold the user institution responsible. I/Weconfirm to have understood that the introduction of this facility may also give rise to operational risks and hereby take full responsibility. I/We undertake to keep sufficient funds in the funding account on the date of executionof standing instruction. I/We have not received nor been induced by any rebate or gifts, directly or indirectly, in making this investment. The ARN holder has disclosed to me/us all the commissions (in the form of trail commissionor any other mode), payable to him/them for the different competing Schemes of various Mutual Funds from amongst which the Scheme is being recommended to me/us. I/We hereby agree to avail the TOP UP facility for SIPand authorize my bank to execute the ECS/Standing Instruction/Direct Debit for a further increase in installment from my designated account. I/We agree that AMC/Mutual Fund (including its affiliates), and any of its officers directors,personnel and employees, shall not be held responsible for any delay / wrong debits on the part of the bank for executing the standing instructions of additional sum on a specified date from my account. I/We hereby understandand confirm that ICICI Prudential Asset Management Company would not be liable for any delay in crediting the scheme collection accounts by the Service Providers which may result in a delay in application of NAV.

Authorisation of the Bank Account Holder for Auto Debit (ECS)/Standing Instruction/Direct Debit

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Application No.SIP REGISTRATION CUM MANDATE FORM

[For investment through ECS (Debit Clearing)/Direct Debit Facility/Standing Instruction]

FIRST MIDDLE LASTMr. Ms. M/s

Sole/First Applicant’s Name Existing Folio No.

� �

I/We, Mr. / Ms. / M/s. (NAME AS PER THE BANK RECORD) (NAME AS PER THE BANK RECORD)

hereby authorise ICICI Prudential Mutual Fund and their authorised service providers to debit from my/our Bank Account No. mentioned below (hereinafter referred as “funding account”) by ECS (Debit Clearing)/Direct Debit for collection of SIP payments/authorise the bank to record a Standing Instruction for debit to my bank account as mentioned below, as instructed by ICICI Prudential Mutual Fund.

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Name of Bank


Branch Name

9 Digit MICR code

PARTICULARS OF BANK ACCOUNT

(Please enter the 9 digit number that appears next to the cheque number). In case of At Par accounts, kindly provide the correctMICR number of the bank branch. MICR code starting and/or ending with 000 are not valid for ECS.

TOP UP Amount*: Rs._____________________ TOP UP Frequency: Half Yearly Yearly

* TOP UP amount has to be in multiples of Rs.500 only. [Please refer to Terms & Conditions No. C(5)]

SIP TOP UP (Optional)(Tick to avail this facility)

Signature(s) as per ICICI Prudential Mutual Fund Records (Mandatory)

SIP Frequency: Monthly Quarterly

(Default SIP frequency is Monthly)

In case of Quarterly SIP, only Yearly frequency is availableunder SIP TOP UP.

YOUR CONFIRMATION/DECLARATION: I/We hereby declare that I/we do not have any existing Micro SIPs which together with the current application will result in a total investments exceeding Rs.50,000in a year as described in the Instruction No.IV(d) of the common application form. The ARN holder has disclosed to me/us all the commissions (in the form of trail commission or any other mode), payable to himfor the different competing Schemes of various Mutual Funds from amongst which the Scheme is being recommended to me/us.

SIP Date: 7th

ACKNOWLEDGEMENT SLIP

(To be filled in by the investor)

Folio No./

Application No.SIP Amount Rs.___________________


Scheme Name:______________________

Option:____________________________

Sub-Option:_________________________

Branch City

10th 15th

SIP StartMonth/Year

12 / 2016 12 / 2018

12 / 2023 12 / 2099

Or other please fill in below

M M Y Y Y Y

25th

M M Y Y Y Y

DEMAT ACCOUNT DETAILS [Optional - Please refer Instruction No. C(7)] NSDL OR CDSL

Investor must read Key Scheme Features and Instructions before completing this form. All sections to be completed in ENGLISH in BLACK / BLUE COLOURED INK and in BLOCK LETTERS.So

le/F

irst

Hol

der

2n

dH

olde

r

3rd

Hol

der

(Please note for unit holder opting to invest in demat, please ensure that the bank account linked with the demat account is mentioned here.)

SIP End

Month/

Year

OPTION: SUB-OPTION: Dividend Frequency: AEP Frequency:

PLAN: Regular DirectScheme Name: ICICI PRUDENTIAL ________________________________________________

SIP TOP UP Amount Rs.__________________ Frequency: Half Yearly Yearly

Acknowledgement Stamp

Sole

/Firs

tH

olde

r

2n

dH

olde

r

3rd

Hol

der

The Trustee, ICICI Prudential Mutual Fund, I/We have read and understood the contents of the Scheme Information Document of the following Scheme and the terms and conditions of the SIP Enrolment.

D D M M Y YDate:New Registration Cancellation Change in Bank Account*[*Please provide a cancelled cheque]Please tick (�)



TRANSACTION CHARGES FOR APPLICANTS THROUGH DISTRIBUTORS ONLY [Refer Instruction IX and please tick (�) any one]


BROKER CODE (ARN CODE)

SERIAL NUMBER, DATE & TIME OF RECEIPTFOR OFFICIAL USE ONLYSUB-BROKER ARN CODE Employee Unique

Identification No. (EUIN)

SUB-BROKER CODE(As allotted by ARN holder)

Declaration for "execution-only" transaction (only where EUIN box is left blank) (Refer Instruction No. X)I/We hereby confirm that the EUIN box has been intentionally left blank by me/us as this is an “execution-only” transaction without any interaction oradvice by the employee/relationship manager/sales person of the above distributor or notwithstanding the advice of in-appropriateness, if any, providedby the employee/relationship manager/sales person of the distributor and the distributor has not charged any advisory fees on this transaction.


ARN- E

Please refer instructions and Key Scheme Features for options, sub-options and other facilities available under each scheme of the Fund.

Each SIP Amount: Rs. Rupees in words: _______________________________

___________________________________________________________________________________________________

FIRST INSTALLMENT THROUGH CHEQUE/DD First Cheque/DD No._________________________ Dated ______________________

Drawn on Bank __________________________________________________ Amount Rs.

Bank Branch ____________________________________________________ City ____________________________________

ashok

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A) SIP Payment through Electronic Clearing Service (DebitClearing) of the Reserve Bank of India (RBI)

1. The bank account provided for ECS (Debit) should participate in local MICR clearing.

2. SIP auto debit is available only on specific dates of the month viz. 7th/10th/15th/25th. In case 7th/10th/15th/25th is a holiday, then next business day. In case the AutoDebit does not take effect for three consecutive times then the SIP would be liablefor cancellation.

3. In case of SIP transaction where, the mode of payment is through StandingInstruction/Auto Debit facility (offered by select banks) or ECS, investors are notrequired to do an initial purchase transaction for the minimum amount as applicable.However, investors are required to submit SIP request at least 30 days prior to thedate of first installment.

Investors/unitholders subscribing for SIP are required to submit SIP request at least30 days prior to the date of first debit date and SIP start date shall not be beyond 90days monthly SIP and 100 days for Quarterly SIP from the date of submission of SIPapplication.

The applicant will have the right to discontinue SIP at any time he or she so desiresby providing a written request at the office of the ICICI Prudential Mutual FundCustomer Service Centres. Notice of discontinuance should be received 30 daysprior to the subsequent SIP date.

All terms and conditions for SIP, including Exit Load, if any, prevailing in the date ofSIP enrolment/registration by the fund shall be levied in the Scheme.

4. The investor agrees to abide by the terms and conditions of ECS facility of ReserveBank of India (RBI).

5. Investor will not hold ICICI Prudential Mutual Fund, its registrars and other serviceproviders responsible if the transaction is delayed or not effected or the investorbank account is debited in advance or after the specific SIP date due to variousclearing cycles for ECS.

6. ICICI Prudential Mutual Fund reserves the right to reject any application withoutassigning any reason thereof.

7. In case of “At Par” cheques, investors need to mention the MICR number of his actualbank branch.

8. New Investor: If the investor fails to mention the scheme name in the SIP MandateForm, then the Fund reserves the right to register the SIP as per the scheme nameavailable in the main application form. Incase multiple schemes are mentioned inthe main application form, the Fund reserves the right to reject the SIP request.

9. Existing Investor: If the investor fails to mention the scheme name in the SIP MandateForm, the Fund reserves the right to register the SIP in the existing scheme (eligiblefor SIP) available in the investor’s folio. Incase multiple schemes or Equity LinkedSavings Scheme (ELSS) are available in the folio, the Fund reserves the right toreject the SIP request.

10. Incase SIP date is not selected, then the SIP will be registered on 10th (default date)of each Month/Quarter, as applicable. Further if multiple SIP dates are opted for orif the selection is not clear, then the SIP will be registered for 10th of each Month/Quarter, as applicable.

11. If the investor has not mentioned the SIP start month, SIP will start from the nextapplicable month, subject to completion of 30 days lead time from the receipt of SIPrequest.

12. Incase the SIP ‘End Period’ is incorrect or not mentioned by the investor in the SIPform, then 5 years from the start date shall be considered as default ‘End Period’.

13. Change of Amount: Investors can change the SIP amount by submitting the followingdocuments 30 days before the next SIP debit date.

a) A new ‘SIP ‘ Form with revised SIP amount details.

b) Letter to discontinue the existing SIP

14. Change of Bank: In order to change the existing bank account for SIP investors needto submit following documents 30 days before the next SIP debit date

• A new ‘SIP’ Form with change of bank details and cancelled cheque of new bank.

15. Conversion of PDC facility in to ECS (Debit Clearing) / Direct Debit Facility/StandingInstruction: Investor with existing SIP facility through Post Dated Cheques can alsoavail of this facility by submitting the following documents 30 days before the nextSIP Debit date

a) A new ‘SIP’ Form along with one cancelled cheque.

b) Letter requesting to cancel the existing SIP through PDCs and for returning allthe remaining PDCs.

B) SIP Payment through Standing Instruction/Direct DebitFacility

1. Standing Instruction/Direct Debit facility is offered to the investors having BankAccount with:

Nature of facility Banks

Standing instruction Axis Bank, HDFC Bank, ICICI Bank, State Bankof India & The Dhanalakshmi Bank Ltd.

Direct debit IDBI Bank, Indusind Bank & Kotak MahindraBank.

Direct debit Allahabad Bank, Bank of Baroda, Bank of India,(Only Core Banking branches*) Corporation Bank, ING Vysya Bank Ltd., Punjab

National Bank, The Federal Bank Ltd., UCOBank and Union Bank of India.

* Please contact your local bank branch to confirm if it offers core banking facility.

2. The applicant will have the right to discontinue SIP at any time he or she so desiresby providing a written request at the office of the ICICI Prudential Mutual FundCustomer Service Centres. Notice of discontinuance should be received 30 days priorto the subsequent SIP date.

3. Standing Instructions incomplete in any respect are liable to be rejected.

4. SIP is liable for cancellation if direct debit fails for three consecutive times.

5. The Bank shall not be liable for, nor be in default by reason of, any failure or delay incompletion of its obligations under this Agreement, where such failure or delay iscaused, in whole or in part, by any acts of God, civil war, civil commotion, riot, strike,mutiny, revolution, fire, flood, fog, war, lightening, earthquake, change of Governmentpolicies, unavailability of Bank’s computer system, force majeure events, or anyother cause of peril which is beyond the Bank’s reasonable control and which haseffect of preventing the performance of the contract by the Bank.

C) General Instructions

1. Existing investors need to provide their folio number in this Standing Instruction orthe Auto Debit form and need not to fill in the Common Application Form.

For minimum application amount to be invested in SIP, risk factors, features etc.please refer to the Key Scheme Features.

2. If the investor selects multiple SIP frequencies or fails to choose any of them, thedefault SIP frequency will be Monthly.

3. ICICI Prudential Mutual Fund, its registrars and other service providers shall not beresponsible and liable for any damages/compensation for any loss, damage etc.incurred by the investor. The investor assumes the entire risk of using this facility andtakes full responsibility.

4. For load structure of the schemes, please refer to the Key Scheme Features.

5. SIP TOP UP Facility:

(a) Investors can opt for SIP TOP UP facility, wherein the amount of the SIP can beincreased at fixed intervals.

(b) The TOP UP amount has to be in multiples of Rs.500 only.

(c) The frequency is fixed at Yearly and Half Yearly basis. In case the TOP UP facilityis not opted by ticking the appropriate box and frequency is not selected, theTOP UP facility may not be registered.

(d) In case of Quarterly SIP, only the Yearly frequency is available under SIP TOP UP.

6. The investor hereby agrees to indemnify and not hold responsible, the AMC and itsemployees, the R&T agent and the service providers incase his/her bank is not ableto effect any of the payment instructions for whatsoever reason.

7. Demat/Non-Demat Mode: Investors have an option to hold the Units indematerialized form. Please tick the relevant option of Yes/No for opting/not optingunits in demat form. If no option is excercised, “No” will be the default option.Applicants must ensure that the sequence of names as mentioned in the applicationform matches with that of the account held with the Depository Participant. If thedetails mentioned in the application are incomplete/incorrect or not matched withthe Depository data, the application shall be treated as invalid and the units wouldbe allotted in Non-Demat mode. The application form should mandatorilyaccompany the latest Client investor master/ Demat account statement. Dematoption will be not be available for Daily/Weekly/Fortnightly dividend options. Investorsdesiring to get allotment of units in demat mode must have a beneficiary accountwith a Depository Participant (DP) of the Depositories i.e. National SecuritiesDepositories Limited (NSDL) / Central Depository Services Limited (CDSL).

Allotment letters would be sent to investors who are allotted units in Demat modeand a Statement of Accounts would be sent to investors who are allotted units innon-Demat mode. Investors are requested to note that Units held in dematerializedform are freely transferable except units held in Equity Linked Savings Scheme’s(ELSS) during the lock-in period.

The units will be allotted based on the applicable NAV as per the SID and will becredited to investor’s Demat account on weekly basis upon realization of funds. Fore.g. Units will be credited to investors Demat account every Monday for realizationstatus received in last week from Monday to Friday.

The investors shall note that for holding the units in demat form, the provisions laidin the Scheme Information Document (SID) of respective Scheme and guidelines/procedural requirements as laid by the Depositories (NSDL/CDSL) shall be applicable.In case the unit holder wishes to convert the units held in non-demat mode to dematmode or vice versa at a later date, such request along with the necessary formshould be submitted to their Depository Participant(s).

Units held in demat form will be freely transferable, subject to the applicableregulations and the guidelines as may be amended from time to time.

TERMS AND CONDITIONS

36

SMART FEATURES FORMSTP / SWP / DTP / TRIGGER / LIQUITY

Please read INSTRUCTIONS carefully. All sections to be completed in ENGLISH in BLACK / BLUE COLOURED INK and in BLOCK LETTERS.

Application No.

� �

Note: All future communications in connection with this application should be addressed to the nearest ICICI Prudential Mutual Fund Customer Service Centre, quoting full name ofthe first applicant, the application serial number, the name of the scheme, the amount invested, date and the place of the Customer Service Centre where application was lodged.

1 EXISTING UNITHOLDERS INFORMATION If you have an existing folio no. with PAN & KYC validation please mention your name & folio No.

Name FIRST MIDDLE LAST Folio No.Mr. Ms. M/s

Application No.FOR ANY ASSISTANCE OR FURTHER INFORMATION PLEASE CONTACT US

ICICI Prudential Asset Management Company LimitedCentral Service Office, 2nd Floor, Block B-2, Nirlon Knowledge Park, Western Express Highway, Goregaon (East), Mumbai - 400 063. India


TOLL FREE NUMBER 1800 222 999 (MTNL/BSNL) 1800 200 6666 (OTHERS) EMAIL [email protected] WEBSITE www.icicipruamc.com

4 SYSTEMATIC WITHDRAWAL PLAN (SWP) (Please refer to instruction No. XVI)

Frequency Monthly QuarterlyWithdrawalAmount `

Name of scheme ICICI PRUDENTIAL (SCHEME FROM WHICH YOU WISH TO WITHDRAWAL AMOUNT)

5 DIVIDEND TRANSFER (DTP) (Please refer to instruction No. XVII)

Name of Source scheme ICICI PRUDENTIAL

Name of Target scheme ICICI PRUDENTIAL

(SCHEME NAME & DIVIDEND FREQUENCY FROM WHICH YOU WISH TO OPT FOR DTP)

(SCHEME INTO WHICH YOU WISH TO TRANSFER DIVIDEND)

Option & Sub option (Please � the appropriate boxes or fill in the options/sub-options, only if applicable to the scheme into which you wish to transfer dividend)

3 SYSTEMATIC TRANSFER PLAN (STP) (Please refer to instruction No. XV)

Name of scheme: ICICI PRUDENTIAL (SCHEME FROM WHICH YOU WISH TO TRANSFER AMOUNT)

Option & Sub option (Please � the appropriate boxes or fill in the respective options/sub-options/facilities, in which you plan to invest)

Name of scheme: ICICI PRUDENTIAL (SCHEME INTO WHICH YOU WISH TO TRANSFER AMOUNT)

Option & Sub option (Please � the appropriate boxes or fill in the respective options/sub-options/facilities, in which you plan to invest)

`No. of Installments(Minimum 6 installments)

Installment Amount(Minimum of Rs.1,000)

Note: In case of Daily STP the minimum installment amount is ` 250 & in multiplesof ` 50 thereof and minimum installment criteria shall not be applicable. (Daily STPis available for specific source & target schemes, please refer to instruction XV)

Transfer Frequencies Daily Weekly Monthly Quarterly STP Date (Monthly frequency only) 7th 10th 15th 25th Last day of Month

Start Date: End Date:M M / Y Y Y Y M M / Y Y Y Y

Dividend Frequencies:

PLAN:

Regular Direct AEP Frequencies:

SUB-OPTION:


OPTION:PLAN:

Regular Direct AEP Frequencies:

SUB-OPTION:


OPTION:PLAN:

Regular Direct

SUB-OPTION:


OPTION:PLAN:

Regular Direct

SUB-OPTION:OPTION:



Identification No. (EUIN)SUB-BROKER CODE

(As allotted by ARN holder)

Declaration for "execution-only" transaction (only where EUIN box is left blank) (Refer Instruction No. X)I/We hereby confirm that the EUIN box has been intentionally left blank by me/us as this is an “execution-only” transaction without any interaction or adviceby the employee/relationship manager/sales person of the above distributor or notwithstanding the advice of in-appropriateness, if any, provided by theemployee/relationship manager/sales person of the distributor and the distributor has not charged any advisory fees on this transaction.


Upfront commission shall be paid directly by the investor to the AMFI registered Distributors based on the investors’ assessment of various factors including the service rendered by the distributor.

2 APPLICANT(S) DETAILS (Please Refer to Instruction No. II (b) )

Enclosed (Please �)§ KYC Acknowledgement Letter

Date of Birth**

Name of * # GUARDIAN IN CASE FIRST APPLICANT IS A MINOR OR CONTACT PERSON IN CASE OF NON-INDIVIDUAL APPLICANTS

Enclosed (Please �)§

KYC Acknowledgement Letter



D D M M Y Y Y Y

PAN*

PAN*

PAN*

PAN*

Sole/FirstApplicant


3rd Applicant

2nd Applicant

Mr. Ms.

Relationship withMinor applicant

Natural guardian

Court appointed guardian


Mr. Ms. FIRST MIDDLE LAST

Mr. Ms. FIRST MIDDLE LAST

Cumulative – AEP Regular Option: Encashment of units is subject to declaration of dividend in the respective Scheme(s). Please refer to Instruction no. VII(g)

* Mandatory information – If left blank the application is liable to be rejected.** Mandatory in case the Sole/First applicant is minor.§ For KYC requirements, please refer to the instruction Nos. II b(5) & VII

# Name of Guardian/Contact Person is Mandatory in case of Minor/Non-Individual Investor.For documents to be submitted on behalf of minor folio refer instruction II-b(2)

ARN- E

AEP Frequencies:

ashok

Typewritten Text

023534

37


Please Retain this Slip

To be filled by investor Subject to realization of cheque & furnishing of

mandatory information / documents.

Scheme

Entry Trigger STP SWP DTP Liquity

ICICI PRUDENTIAL Rs. AMOUNT UNITS

SOURCE / FROM SCHEME

� �

ICICI PRUDENTIAL FLEXIBLE INCOME PLAN

Growth OR Dividend Option - Payout Reinvestment Daily Weekly Fortnightly Monthly Quarterly Dividend Others

SOURCE SCHEMES & OPTIONS (Appreciation / Dividend amount to be transferred from - Please � any one of the Scheme / Options)

ICICI PRUDENTIAL LIQUID PLAN

Growth OR Dividend Option - Payout Reinvestment Daily Weekly Monthly Quarterly Half Yearly Yearly Dividend Others

ICICI PRUDENTIAL SAVINGS PLAN

TARGET SCHEMES & OPTIONS

(Appreciation / Dividend amount to be transferred from - Please � any one of the Schemes – only Growth Option available)

ICICI Prudential Focused Bluechip Equity Fund ICICI Prudential Dynamic Plan ICICI Prudential Infrastructure Fund

ICICI Prudential Top 200 Fund ICICI Prudential Discovery Fund ICICI Prudential Midcap Fund

ICICI Prudential Top 100 Fund ICICI Prudential Export and Other Services Fund

6 ENTRY TRIGGER REGISTRATION / CANCELLATION (Please refer to instruction No. XVIII)

Amount / Units to be triggered From (Please � Source Scheme)

ICICI Prudential Savings Fund ICICI Prudential Flexible Income Plan ICICI Prudential Income Plan ICICI Prudential Short Term Plan

ICICI Prudential Liquid Plan ICICI Prudential Long Term Plan ICICI Prudential Ultra Short Term Plan

Cancellation (Of any trigger set-up registered earlier)Please �� New Registration Update existing registration


The Trustee, ICICI Prudential Mutual Fund, I/We have read and understood the Scheme Information Document/Key Information Memorandum of the Scheme(s). I/We apply for the units of the Fund and agree to abideby the terms, conditions, rules and regulations of the scheme and other statutory requirements of SEBI, AMFI, Prevention of Money Laundering Act, 2002 and such other regulations as may be applicable from timeto time.I/We confirm to have understood the investment objectives, investment pattern, and risk factors applicable to Plans/Options under the Scheme(s). I/we have not received nor been induced by any rebateor gifts, directly or indirectly, in making this investment. I/We declare that the amount invested in the Scheme is through legitimate sources only and is not designed for the purpose of contravention or evasion ofany Act, Regulations or any other applicable laws enacted by the Government of India or any Statutory Authority. I/We agree that in case my/our investment in the Scheme is equal to or more than 25% of the corpusof the plan, then ICICI Prudential Asset Management Co. Ltd.(the 'AMC'), has full right to refund the excess to me/us to bring my/our investment below 25%. I/We hereby declare that I am/we are not US Person(s).I/We hereby declare that I/we do not have any existing Micro SIPs which together with the current application will result in a total investments exceeding Rs.50,000 in a year. The ARN holder has disclosed to me/us all the commissions (in the form of trail commission or any other mode), payable to him for the different competing Schemes of various Mutual Funds from amongst which the Scheme is being recommendedto me/us. I/We interested in receiving promotional material from the AMC via mail, SMS, telecall, etc. If you do not wish to receive, please call on tollfree no. 1800 222 999 (MTNL/BSNL) or 1800 200 6666 (Others).I/We hereby confirm that the EUIN box has been intentionally left blank by me/us as this is an “execution-only” transaction without any interaction or advice by the employee/relationship manager/sales personof the above distributor or notwithstanding the advice of in-appropriateness, if any, provided by the employee/relationship manager/sales person of the distributor and the distributor has not charged any advisoryfees on this transaction.

Growth OR Dividend Option - Payout Reinvestment Daily Weekly Fortnightly Monthly Quarterly Dividend Others

SCHEME AND OPTION

TARGET / TO SCHEME FREQUENCY & NO. OF INSTALLMENTS

EXISTING FOLIO NO.

7 LIQUITY FACILITY (Please refer to instruction No. XIX)

TOTAL AMOUNT TO BE REGISTERED

AMOUNT IN FIGURES

AMOUNT IN WORDS

% drop in NAV (Please �) or BSE Sensex Value

5% or

10% or

15% or

20% or

(Please refer instruction XVIII(1))

TRIGGER AMOUNT

IN MULTIPLES OF 100 POINTS




% of Total Registered Amount to be Transferred

MINIMUM 10% AND IN MULTIPLE OF 5%




`

100 % of Total Registered Amount

TRIGGER LEVEL


Rupees

Amount / Units to be triggered To (Please � Target Scheme)

ICICI Prudential Dynamic Plan ICICI Prudential Focused Bluechip Equity Fund ICICI Prudential Index Fund ICICI Prudential Balanced Fund ICICI Prudential Top 100 Fund ICICI Prudential Top 200 Fund ICICI Prudential Target Returns Fund ICICI Prudential Discovery Fund ICICI Prudential Balanced Advantage Fund

PLAN: Regular OR Direct




SUB-OPTION: Divident Reinvestment OR Dividend Payout

Dividend Frequencies: Daily Weekly Fortnightly Monthly Quarterly Half Yearly Annual Dividend Others

PLAN:

Regular Direct

SUB-OPTION: Divident Reinvestment OR Dividend Payout

Dividend Frequencies: Daily Weekly Fortnightly Monthly Quarterly Half Yearly Annual Dividend Others

OPTION: Growth/Cumulative OR DividendPLAN:

Regular Direct

OPTION: Growth/Cumulative Dividend Bonus

38

ICICI PRUDENTIAL SIP PLUS

Common Application for SIP Plus

Application No.

Please read the INSTRUCTIONS carefully. All the sections to be completed in BLOCK LETTERS in ENGLISH with BLACK / BLUE COLOURED INK.

FOR ANY ASSISTANCE OR FURTHER INFORMATION PLEASE CONTACT US

ICICI Prudential Asset Management Company LimitedCentral Service Office, 2nd Floor, Block B-2, Nirlon Knowledge Park, Western Express Highway, Goregaon (East), Mumbai - 400 063. India


TOLL FREE NUMBER 1800 222 999 (MTNL/BSNL) 1800 200 6666 (OTHERS) EMAIL [email protected] WEBSITE www.icicipruamc.comNote: All future communications in connection with this application should be addressed to the nearest ICICI Prudential Mutual Fund Customer Service Centre, quoting full name ofthe first applicant, the application serial number, the name of the scheme, the amount invested, date and the place of the Customer Service Centre where application was lodged.

Application No.

Please � if you wish to receive Account statement / Annual Report/ Other statutory information via Post instead of Email

* Mandatory information – If left blank the application is liable to be rejected. £ Please refer to instruction no.VI

Please � any of the frequencies to receive Account Statement through e-mail £ : Daily Weekly Monthly Quarterly Half Yearly Annually

1 APPLICANT(S) DETAILS (Please refer to Instruction No. II)


Date of Birth*


Date of Birth


Date of Birth

D D M M Y Y Y Y

D D M M Y Y Y Y

D D M M Y Y Y Y

PAN*

PAN*

PAN*

Sole/FirstApplicant


Mr. Ms. FIRST MIDDLE LAST3rd Applicant

Mr. Ms. FIRST MIDDLE LAST2nd Applicant


§ For KYC requirements, please refer to the instruction Nos. II(3) & VII

NRI/PIO Resident Individual

Status of First Applicant [Please tick (�)]

Correspondence Address (Please provide full address)*

HOUSE / FLAT NO.

STREET ADDRESS

STREET ADDRESS

COUNTRY PIN CODE

Overseas Address (Mandatory for NRI / FII Applicants)

HOUSE / FLAT NO.

STREET ADDRESS

STREET ADDRESS

PIN CODE

Tel. (Res.)

Occupation [Please tick (�)] Professional Business Retired Housewife Service Student Others (Please specify)

CITY / TOWN STATE

COUNTRY

CITY / TOWN STATE

Single Joint Anyone or Survivor

(Default option: Anyone or Survivor)

Mode of holding [Please tick (�)]

Mobile

FaxTel. (Off.)

Email £

Gender* Male Female [Please tick (�)]

� �



TRANSACTION CHARGES FOR APPLICANTS THROUGH DISTRIBUTORS ONLY [Refer Instruction IX and please tick (�) any one]








MA

ND

AT

OR

Y

2 BANK ACCOUNT (PAY-OUT) DETAILS OF SOLE/FIRST APPLICANT (Please Refer to Instruction No. III)

Name of Bank


Branch Name

9 Digit MICR code 11 Digit IFSC Code

Branch City

Mandatory information – If left blank the application is liable to be rejected. (Mandatory to attach proof, in case the pay-out bank account is different from the bank account.)

For unit holders opting to hold units in demat form, please ensure that the bank account linked with the demat account is mentioned here.

Enclosed (Please �):

Bank Account Details Proof Provided.

ARN- E

ashok

Typewritten Text

ashok

Typewritten Text

023534

39

Subsequent SIP Instalment Details

Start Month/ SIP Plus

Year Tenure

PER CHEQUE`Amount InvestedFrom Cheque No. to Cheque No.

No. of Cheques Drawn on BANK / BRANCH

*Default SIP Frequency is Monthly. ¶ PDCs - Post Dated Cheques

M M Y Y Y Y

Applications with Third Party Cheques, prefunded instruments etc. and in circumstances as detailed in AMFI Circular No.135/BP/16/10-11 shall be processed in accordance with the said

circular. Please read the instruction no. XIV(e). Third Party Payment Declaration form is available in www.icicipruamc.com or ICICI Prudential Mutual Fund branch offices.


Please Retain this SlipICICI PRUDENTIAL SIP PLUS

To be filled in by the Investor.

Subject to realization of cheque and furnishing of Mandatory Information.

Scheme

From Cheque/DD No.

From Date

TOTAL AMOUNTICICI PRUDENTIAL

To Cheque/DD No.

AMOUNT PER CHEQUE

BANK AND BRANCH

` `SCHEME AND OPTION

M M Y YY Y

Payment Details for First Cheque/DD

B`DD Charges

(if applicable)A + B`

Amount

Invested

Mode of Payment Cheque DD Funds Transfer NEFT RTGS

Cheque /

DD NumberD D M M Y YDate

Amount PaidA`

AccountNumber

55 yrs – Your Current Age yrs = yrs For more information ref. Instruction No. XV(5).

(E.g. Your Current Age is 40 years, then your SIP Plus Tenure would be 55 years – 40 years = 15 years.)

55 yrs – Your Current Age yrs = yrs For more information ref. Instruction No. XV(5).

(E.g. Your Current Age is 40 years, then your SIP Plus Tenure would be 55 years – 40 years = 15 years.)

SIP Plus Tenure

Account Type NRE NRO Savings Current FCNR

Bank Name Bank Branch & City

� �

4 NOMINATION DETAILS (Refer instruction IV)

Nominee

Guardian

Nominee’s

Address

(Mandatory)

SIGNATURE OF NOMINEE / GUARDIAN, IF NOMINEE

IS A MINOR

HOUSE / FLAT NO STREET ADDRESS

Date of BirthNAME OF NOMINEE

MANDATORY, IF NOMINEE IS A MINOR

CITY / TOWN PIN CODE

(Mandatory if nominee is minor)

Relationship with the Nominee: Father Mother Legal Guardian [Please tick (�)]

D D M M Y Y

I/We hereby nominate the undermentioned nominee to receive the amount to my/our credit in event of my/our death.

The Trustee, ICICI Prudential Mutual Fund,I/We have read and understood the Scheme Information Document/Key Information Memorandum of the Scheme(s). I/We apply for the units of the Fund and agree to abide by the terms, conditions, rules and regulations ofthe scheme and other statutory requirements of SEBI, AMFI, Prevention of Money Laundering Act, 2002 and such other regulations as may be applicable from time to time.I/We confirm to have understood the investmentobjectives, investment pattern, and risk factors applicable to Plans/Options under the Scheme(s). I/we have not received nor been induced by any rebate or gifts, directly or indirectly, in making this investment. I/We declarethat the amount invested in the Scheme is through legitimate sources only and is not designed for the purpose of contravention or evasion of any Act, Regulations or any other applicable laws enacted by the Governmentof India or any Statutory Authority. I/We agree that in case my/our investment in the Scheme is equal to or more than 25% of the corpus of the plan, then ICICI Prudential Asset Management Co. Ltd.(the 'AMC'), has full rightto refund the excess to me/us to bring my/our investment below 25%. I/We hereby declare that I am/we are not US Person(s). I/We hereby declare that I/we do not have any existing Micro SIPs which together with thecurrent application will result in a total investments exceeding Rs.50,000 in a year. The ARN holder has disclosed to me/us all the commissions (in the form of trail commission or any other mode), payable to him for thedifferent competing Schemes of various Mutual Funds from amongst which the Scheme is being recommended to me/us. I/We interested in receiving promotional material from the AMC via mail, SMS, telecall, etc. If youdo not wish to receive, please call on tollfree no. 1800 222 999 (MTNL/BSNL) or 1800 200 6666 (Others).

DECLARATION FOR AVAILING INSURANCE COVER

I am informed about the arrangement between ICICI Prudential Mutual Fund and the Insurance Company and about the details of the Master Policy Document. I understand that I am eligible to avail cover under sucharrangement and hereby wish to avail the said insurance cover.



3 INVESTMENT & PAYMENT DETAILS (Refer Instruction No. XII) For Plans & Sub-options please see Key Scheme Features for the scheme specific details.

SIP Through ECS/Standing Instruction / Direct Debit PDCs ¶

Name of scheme ICICI PRUDENTIAL

SIP Frequency* Monthly QuarterlySIP Date 7th 10th 15th 25th

Micro Investment upto Rs. 50,000/- (Please �) Mandatory. [Please refer instruction No. V(h)]

Sole/First

Applicant

2nd Applicant

3rd Applicant




Option & Sub option (Please � the appropriate boxes or fill in the resepective options/sub-otions/facilities in which you plan to invest)

SUB-OPTION:


OPTION:PLAN:

Regular DirectAEP Frequencies:

Please refer instructions and Key Scheme Features for options, sub-options and other facilities available under each scheme of the Fund.

40

The Trustee, ICICI Prudential Mutual Fund,I/We have read and understood the contents of the Scheme Information Document of the following Scheme and the terms and conditions of the SIP Enrolment.

SIGNATURE(S) OF BANK ACCOUNT HOLDER(S) AS IN BANK RECORDS (Mandatory)

I/We have read and understood the contents of the Scheme Information Document(s) and Statement of Additional Information and the terms & conditions of SIP enrolment and ECS (Debit Clearing) / DirectDebit / Standing Instruction and agree to abide by the same. I /We hereby apply to the Trustee of ICICI Prudential Mutual Fund for enrolment under the SIP of the following Scheme(s)/ Plan(s) / Option(s) andagree to abide by the terms and conditions of the same. I/We hereby declare that the particulars given above are correct and express my willingness to make payments referred above through participationin ECS. This is to inform I/we have registered for the RBI's Electronic Clearing Service (Debit Clearing) and that my payment towards my investment in ICICI Prudential Mutual Fund shall be made from my/our below mentioned bank account with your bank. I/We authorise the representative carrying this ECS mandate Form to get it verified & executed. I/We authorise the bank to honour the instructions asmentioned in the application form. I/We also hereby authorise bank to debit charges towards verification of this mandate, if any. I/We agree that AMC/Mutual Fund (including its affiliates), and any of its officersdirectors, personnel and employees, shall not be held responsible for any delay/wrong debits on the part of the bank for executing the direct debit instructions of additional sum on a specified date from myaccount. If the transaction is delayed or not effected at all for reasons of incomplete or incorrect information, I/We would not hold the user institution responsible. I/We confirm to have understood that theintroduction of this facility may also give rise to operational risks and hereby take full responsibility. I/We undertake to keep sufficient funds in the funding account on the date of execution of standing instruction.I/We have not received nor been induced by any rebate or gifts, directly or indirectly, in making this investment. The ARN holder has disclosed to me/us all the commissions (in the form of trail commissionor any other mode), payable to him/them for the different competing Schemes of various Mutual Funds from amongst which the Scheme is being recommended to me/us. I/We agree that AMC/Mutual Fund(including its affiliates), and any of its officers directors, personnel and employees, shall not be held responsible for any delay / wrong debits on the part of the bank for executing the standing instructions ofadditional sum on a specified date from my account. I/We hereby understand and confirm that ICICI Prudential Asset Management Company would not be liable for any delay in crediting the scheme collectionaccounts by the Service Providers which may result in a delay in application of NAV.

Authorisation of the Bank Account Holder for Auto Debit (ECS)/Standing Instruction/Direct Debit

BA

NK

MA

ND

AT

E S

EC

TIO

N (

Man

dato

ry)

�

Application No.

Please read the INSTRUCTIONS carefully. All the sections to be completed in BLOCK LETTERS in ENGLISH with BLACK / BLUE COLOURED INK.

Applicant need to fill in the Main SIP Plus Application Form and submit along with this mandate form.

ICICI PRUDENTIAL SIP PLUS

SIP Registration-cum-Mandate Form for SIP Plus

[Application for investment through ECS (Debit Clearing)/

Direct Debit Facility/Standing Instruction]

FIRST MIDDLE LASTMr. Ms.

Sole/First Applicant’s Name

D D M M Y YDate:New Registration CancellationPlease tick (�)

I/We, Mr. / Ms. / M/s. (NAME AS PER THE BANK RECORD) (NAME AS PER THE BANK RECORD)

hereby authorise ICICI Prudential Mutual Fund and their authorised service providers to debit from my/our Bank Account No. mentioned below (hereinafter referred as “funding account”) by ECS (Debit Clearing)/Direct Debit for collection of SIP payments/authorise the bank to record a Standing Instruction for debit to my bank account as mentioned below, as instructed by ICICI Prudential Mutual Fund.

�

Enclosed [please tick (�)]: Blank cancelled cheque Photocopy of Cheque [Please refer to Instruction No. C(5)]

Name of Bank

Account NumberAccount Type

Branch Name

9 Digit MICR code

PARTICULARS OF BANK ACCOUNT

(Please enter the 9 digit number that appears next to the cheque number). In case of At Par accounts, kindly provide the correctMICR number of the bank branch. MICR code starting and/or ending with 000 are not valid for ECS.

Scheme Name: ICICI PRUDENTIAL __________________________________________________________

Plan & Option*: ________________________________ Sub-Option*: _______________________________

Each SIP Amount: Rs. Rupees in words: _______________________________

____________________________________________________________________________________________________

Signature(s) as per ICICI Prudential Mutual Fund Records (Mandatory)


(Default SIP frequency is Monthly)

YOUR CONFIRMATION/DECLARATION: I/We hereby declare that I/we do not have any existing Micro SIPs which together withthe current application will result in a total investments exceeding Rs.50,000 in a year. The ARN holder has disclosed to me/us all thecommissions (in the form of trail commission or any other mode), payable to him for the different competing Schemes of variousMutual Funds from amongst which the Scheme is being recommended to me/us.

SIP Date: 7th

Branch City

10th 15th

SIP StartMonth/Year

25th

M M Y Y Y Y

SIP Plus Tenure

55 yrs – Your Current Age yrs

= yrs

For more information ref. Instruction No. XIII(5).

NRE NRO Savings Current FCNR

1st

Ho

lde

r

2n

d H

old

er

3rd

Ho

lde

r

1st

Ho

lde

r

2n

d H

old

er

3rd

Ho

lde

r

*Please refer to the scheme related documents available under AMC’s website www.icicipruamc.com or with any of its branches.

Direct

Regular

Plan (Please �)

41

A) SIP Payment through Electronic Clearing Service (Debit Clearing)of the Reserve Bank of India (RBI)

1. The bank account provided for ECS (Debit) should participate in local MICR clearing.

2. SIP auto debit is available only on specific dates of the month viz. 7th/10th/15th/25th. In case7th/10th/15th/25th is a holiday, then next business day. In case the Auto Debit does not takeeffect for three consecutive times then the SIP would be liable for cancellation.

3. In case of SIP transaction where, the mode of payment is through Standing Instruction/AutoDebit facility (offered by select banks) or ECS, investors are not required to do an initialpurchase transaction for the minimum amount as applicable. However, investors are requiredto submit SIP request at least 30 days prior to the date of first instalment.

Investors subsribing for SIP are required to submit SIP request at least 30 days prior to thedate of first debit date and SIP start date shall not be beyond 90 days for monthly SIP and 100days for Quarterly SIP from the date of submission of SIP application.

The applicant will have the right to discontinue SIP at any time he or she so desires by providinga written request at the office of the ICICI Prudential Mutual Fund Customer Service Centres.Notice of discontinuance should be received 30 days prior to the subsequent SIP date.

All terms and conditions for SIP, including Exit Load, if any, prevailing in the date of SIPenrolment/registration by the fund shall be levied in the Scheme.

4. The investor agrees to abide by the terms and conditions of ECS facility of Reserve Bank ofIndia (RBI).

5. Investor will not hold ICICI Prudential Mutual Fund, its registrars and other service providersresponsible if the transaction is delayed or not effected or the investor bank account is debitedin advance or after the specific SIP date due to various clearing cycles for ECS.

6. ICICI Prudential Mutual Fund reserves the right to reject any application without assigning anyreason thereof.

7. In case of “At Par” cheques, investors need to mentioned the MICR number of his actual bankbranch.

8. If the investor fails to mention the scheme name in the SIP Mandate Form, then the Fund reservesthe right to register the SIP as per the scheme name available in the main application form. Incasemultiple schemes are mentioned in the main application form, the Fund reserves the right toreject the SIP request.

9. Incase SIP date is not selected, then the SIP will be registered on 10th (default date) of eachMonth/Quarter, as applicable. Further if multiple SIP dates are opted for or if the selection is notclear, then the SIP will be registered for 10th of each Month/Quarter, as applicable.

10. If the investor has not mentioned the SIP start month, SIP will start from the next applicablemonth, subject to completion of 30 days lead time from the receipt of SIP request.

B) SIP Payment through Standing Instruction/Direct Debit Facility

1. Standing Instruction/Direct Debit facility is offered to the investors having Bank Account with:

Nature of facility Banks

Standing instruction Axis Bank, HDFC Bank, ICICI Bank, State Bank of India& The Dhanalakshmi Bank Ltd.

Direct debit IDBI Bank, Indusind Bank & Kotak Mahindra Bank.

Direct debit Allahabad Bank, Bank of Baroda, Bank of India,(Only Core Banking branches*) Corporation Bank, ING Vysya Bank Ltd., Punjab

National Bank, The Federal Bank Ltd., UCO Bank andUnion Bank of India.

* Please contact your local bank branch to confirm if it offers core banking facility.

2. Standing Instructions incomplete in any respect are liable to be rejected.

3. SIP is liable for cancellation if direct debit fails for three consecutive times.

4. The Bank shall not be liable for, nor be in default by reason of, any failure or delay in completionof its obligations under this Agreement, where such failure or delay in completion of itsobligations under this Agreement, where such failure or delay is caused, in whole or in part, byany acts of God, civil war, civil commotion, riot, strike, mutiny, revolution, fire, flood, fog, war,lightening, earthquake, change of Government policies, unavailability of Bank's computersystem, force majeure events, or any other cause of peril which is beyond the Bank's reasonablecontrol and which has effect of preventing the performance of the contract by the Bank.

C) General Instructions

1. For minimum application amount to be invested in SIP, risk factors, features etc. please refer tothe scheme related documents available on www.icicipruamc.com or with any of the customerservice centres of ICICI Prudential Mutual Fund.

2. If the investor selects multiple SIP frequencies or fails to choose any of them, the default SIPfrequency will be Monthly.

3. ICICI Prudential Mutual Fund, its registrars and other service providers shall not be responsibleand liable for any damages/compensation for any loss, damage etc. incurred by the investor. Theinvestor assumes the entire risk of using this facility and takes full responsibility.

4. For load structure of the schemes, please refer to the Key Scheme Features.

5. In case of SIP with payment mode as ECS/Auto Debit, investors shall be required to submit acancelled cheque or a photocopy of a cheque of the bank account for which the debit mandateis provided. It is mandatory to submit cancelled cheque copy OR proof of investments madethrough NRE account.

6. The investor hereby agrees to indemnify and not hold responsible, the AMC and its employees,the R&T agent and the service providers incase his/her bank is not able to effect any of thepayment instructions for whatsoever reason.

7. Applicant will be covered under the ICICI Pru Group Term plus plan (UIN: 105N119V01) of ICICIPrudential Life Insurance Company Ltd. © 2012, ICICI Prudential Life Insurance Co. Ltd.

Registered Address: ICICI Pru Life Towers, 1089 Appasaheb Marathe Marg, Prabhadevi, Mumbai-400025. Reg No: 105. For more details on risk factors, terms and conditions, please read thesales brochure before concluding the sale.

SIP PLUS - TERMS AND CONDITIONS

TERMS FOR GROUP LIFE INSURANCE COVER

1. ICICI Prudential SIP Plus as an add-on, optional feature will be available for the followingschemes of ICICI Prudential Mutual Fund:

ICICI Prudential Infrastructure Fund • ICICI Prudential Dynamic Plan • ICICI PrudentialFocused Bluechip Equity Fund • ICICI Prudential Tax Plan • ICICI Prudential Discovery Fund• ICICI Prudential MidCap Fund • ICICI Prudential Top 100 Fund • ICICI Prudential Top 200Fund • ICICI Prudential FMCG Fund • ICICI Prudential Balanced Fund • ICICI PrudentialTechnology Fund • ICICI Prudential Exports and Other Services Fund • ICICI PrudentialBalanced Advantage Fund • ICICI Prudential Indo Asia Equity Fund • ICICI Prudential Banking& Financial Services Fund.

2. The AMC may provide a Group Life Insurance Cover to all Resident Individual/NRI applicantsand fund the premia towards such cover. Non-individuals as well as US Persons/ Persons notof Indian Origin/Sole Proprietorship will not be covered under the insurance cover.

3. The insurance cover will be available for individuals aged above 18 years and not more than 46years, at the time of the first investment.

4. Only the First / Sole unit holder will be covered under the insurance. No insurance cover willbe provided for the second / third unitholder.

5. Tenure of SIP PLUS: 55 Years less the current completed age of the investor.

6 Amount of Life Insurance Cover:

If SIP PLUS continues, the insurance cover would be as follows

• Year 1 : 10 times the monthly SIP PLUS instalment

• Year 2 : 50 times the monthly SIP PLUS instalment

• Year 3 onwards : 100 times the monthly SIP PLUS instalment

All the above mentioned limits are subject to maximum cover of Rs. 20 lacs per investoracross all schemes/plans/folios.

If SIP PLUS discontinues, the insurance cover would be as follows:

• SIP PLUS discontinues before 3 years : Insurance cover stops immediately

• SIP PLUS discontinues after 3 years : Insurance cover equivalent to the value of unitsallotted under SIP PLUS investment at the start of the each policy year, subject to amaximum of 100 times the monthly instalment, capped at the maximum of 20 lacs.

The insurance cover will also cease

• At the end of the tenure. i.e., upon completion of 55 years of age.

• Redemption / switch-out (fully or partly) of units purchased under the scheme in which SIPPLUS facility is availed before the completion of the SIP PLUS tenure.

7. The investor will necessarily be required to furnish his / her date of birth, gender and detailsof the nominee in the application form, in absence of which, no insurance cover can be availedby the investor. The Group Life Insurance Cover will be governed by the terms and conditionsof the insurance policy with the relevant Insurance Company as determined by the AMC.

8. In case of death of the applicant, his / her legal representatives may file a claim directly withthe designated branch of the Insurance Company supported by all relevant documents asrequired by the insurer and the payment of the claim may be made to the legal representativesby the insurance company.

9. All insurance claims will be settled in India and shall be payable in Indian Rupees only. Settlementprocedure will be as stipulated by the Insurance Company. Insurance claims will be directlysettled by the Insurance Company.

10. The AMC will not be responsible or liable for maintaining service levels and/or any delay inprocessing claims arising out of this facility.

11. The Mutual Fund, Trustees, AMC, or their Directors, officers or employees shall not be liable forany claims (including but not limited to rejection of any claim, non-settlement, delays etc.)arising out of the insurance cover provided to the unit holder.

12. The AMC is bringing this offer to the investors of the Scheme only as an additional facility andis not acting as an agent for marketing/sales of insurance policies nor soliciting any business.

13. Subject to what has been stated above, the AMC reserves a right to modify / annul the saidGroup Insurance Cover on a prospective basis. The AMC also reserves the right to change theinsurance company from time to time.

14. The Group Insurance cover will be subject to the following exclusions and such other terms andconditions as may be prescribed by the insurance certificate governing the cover:

a. The Group Insurance cover shall not extend to cover instances of death due to suicide inthe first year of cover.

b. Death within 45 days from the commencement of the SIP instalments except for deathdue to accident

15. The legal representatives will have to file their claims directly with the insurance company.

16. The AMC will not entertain any request for claims.

17. The provision for the Group Life Insurance Policy does not have any bearing on the performanceof the scheme.

18. For the purpose of availing of the SIP Plus facility, a unique folio will be created. If any othertransaction such as additional purchase, fresh purchase, switchin, switchout, SIP, STP, folioconsolidation request, is made under this unique folio, the Insurance cover will be cancelledwith immediate effect.

19. Applications received under the facility are liable to be rejected where the investor is noteligible for the Group Life Insurance/Term Cover.

ICICI Prudential SIP Plus as an add-on, optional feature will be available with specified schemes ofICICI Prudential Mutual Fund. The applicant will be covered under the ICICI Pru Group Term plus plan(UIN: 105N119V01) of ICICI Prudential Life Insurance Company Ltd. Life insurance cover will begoverned by the terms and conditions of the insurance policy. For detailed terms and condition ofinsurance policy, contact the Group Policyholder, i.e., the AMC. The AMC is not acting as an agentfor marketing/sales of insurance policies nor soliciting any business.

42

ICICI Prudential AMC Ltd. - ACKNOWLEDGEMENT SLIP (To be filled in by the investor)

Folio / Application No. First Holder Name

Received request for Trigger facility under Scheme Plan Option

switching into the Scheme ________________________________ Plan____________________ Option _________________________________________________________

In respect of Trigger Option (please �) NAV Appreciation Trigger : On NAV (Switchout Scheme) reaching Rs. _____________ per unit switch the investment /

NAV Stop-Loss Trigger : On NAV (Switchout Scheme) reaching Rs. _______________________ per unit switch the investment /

Specific Date Trigger : On the day of

DETAILS OF TRANSACTION ON WHICH TRIGGER OPTIONS NEED TO BE EXERCISED/CANCELLED

Mention the complete name of the scheme along with the plan. Please tick (�) or fill the appropriate boxe(s) or column(s)

Plans, Options & sub-options

PLAN: Regular Direct OPTION: Cumulative/Growth Dividend Bonus

SUB-OPTION: DIVIDEND FREQUENCIES:

Dividend Payout Daily Fortnighly Quarterly Annual

Dividend Reinvestment Weekly Monthly Half Yearly Dividend Others

SWITCH TO (Name of the Scheme) (Please leave one column blank between words)

Trigger Application/Cancellation Form(Please read the instructions carefully before filling up the form and use separate applicationform for each transaction). Use this form, if you wish to switch units from one scheme toanother based on appreciation/stop-loss on your investment or on a specific date.

SWITCH FROM (Name of the Scheme) (Please leave one column blank between words)

I C I C I P R U D E N T I A L

Application Number

Folio Number (For existing Unitholders)

TRIGGER [Please tick (�) the appropriate box] Registration Cancellation (In case of cancellation, the section ‘‘SWITCH TO’’ and ‘‘TRIGGER OPTIONS’’ need not be filled in)

D D M M Y Y Y YDate:

D D M M Y Y Y Y

Signature, Stamp & Date(Please retain this slip for all the future correspondence with ICICI Prudential MF in relevance to this Trigger.)

I C I C I P R U D E N T I A L

Plans, Options & sub-options

PLAN: Regular Direct OPTION: Cumulative/Growth Dividend Bonus

SUB-OPTION: DIVIDEND FREQUENCIES:

Dividend Payout Daily Fortnighly Quarterly Annual

Dividend Reinvestment Weekly Monthly Half Yearly Dividend Others

AEP– Regular@ OR Appreciation AEP Frequencies: Monthly Quarterly Half Yearly

@Cumulative – AEP Regular Option: Encashment of units is subject to declaration of dividend in the respective Scheme(s). Please refer to Instruction no. XII(g)

I / We have received, read and understood the offer document/key information memorandum.1. Trigger will require folio number in case of existing investors or application form number in case

of new investor.2. Trigger facility will switch all the units in the above mentioned scheme within the respective

Folio Number of the investor.3. Entry and Exit loads for the scheme(s) shall be applicable as mentioned in the the relevant Offer

Document(s)/Addendum(s). The same will also be applicable for SIP / STP / SWP.4. Tigger facility is available in all the Open Ended Schemes of ICICI Prudential Mutual Fund except

SENSEX Prudential ICICI Exchange Traded Fund (SPIcE), ICICI Prudential Index Fund, ICICIPrudential Gold Exchange Traded Fund and ICICI Prudential Nifty ETF.

5. For the switch to happen the minimum purchase/redemption criteria should be met else thetrigger will not be effected.

6. Trigger facility on each scheme will require a separate/independent Trigger request form to befilled. If an investor holds similar schemes in two folios, they will have to register separately forit mentioning the folio number.

INSTRUCTIONS/DECLARATION

7. Target scheme, where units will be switched if option/sub-options are not selected, it will beswitched to the default option (available under the Target Schemes).

8. Switch will be implemented on the day the trigger condition is satisfied. The Trigger is a one timeoperation and will cease once it is exercised.

9. Once switch is done exercising trigger option, the same will not be reversed whatsoever and itwill be final and binding.

10. If trigger is not activated and/or implemented due to reasons, which are beyond the control ofICICI Prudential AMC, the AMC would not be held responsible. Trigger facility is only a facilityextended by the AMC for the convenience of the unit holders and does not form part of any scheme/fund objectives.

11. AMC reserves the right to amend/terminate this facility at any time, keeping in view business/operational exigencies.

I/We have read & understood and agree to abide by the terms and conditions and opt for the Triggerfacility.

Specific NAV Trigger:

NAV Appreciation Trigger : On NAV (Switchout Scheme) reaching Rs. (Rupees in words ______________________________________________________

_______________________________________________________________________) per unit.

NAV Stop-Loss Trigger : On NAV (Switchout Scheme) reaching Rs. _______________ (Rupees in words ______________________________________________________

_______________________________________________________________________) per unit.

TRIGGER OPTIONS (In case of multiple triggers ticked, one whose condition is fulfilled first will be exercised and balance, if any, will be nullified)

Switch the investment:

(NAV per unit should be mention only in multiple of Re. 1)

D D M M Y Y Y YSpecific Date Trigger : On the day of


SERIAL NUMBER, DATE & TIME OF RECEIPT

FOR OFFICIAL USE ONLYSUB-BROKER ARN CODE Employee Unique



Sole/FirstApplicant

SecondApplicant

ThirdApplicant

Name of theSole/First Applicant

Name of theSecond Applicant

Name of theThird Applicant S

IGN

AT

UR

E(S

)

NAME(S) AND SIGNATURE(S) OF THE APPLICANT(S)



Upfront commission shall be paid directly by the investor to the AMFI registered Distributors based on the investors’ assessment of various factors including the service rendered by the distributor.

ARN- E

ashok

Typewritten Text

023534

43

Declaration of Ultimate Beneficial Ownership [UBO](Mandatory for Non-individual Applicant/Investor)

To be filled in BLOCK LETTERS (Please strike off section(s) that is/are not applicable)

Part I: Applicant/Investor details:

Investor Name:

PAN:

Part III: Individuals other than Listed Company / its subsidiary company (i) Category [tick (�)applicable category]:

Details of Ultimate Beneficiary Owners*:

Part II: Listed Company / its subsidiary company

(i) I/We hereby declare that:

(ii) Details of Listed Company^

Our company is a Listed Company, listed on recognized stock exchange in India Our company is a subsidiary of the Listed Company

Our company is controlled by a Listed Company

None of the above

Stock Exchange on which listed ___________________________________________________ Security ISIN ____________________________

Unincorporated association / body of individuals Public Charitable Trust Religious Trust

Unlisted Company Partnership Firm / Limited Liability Partnership Company

Private Trust Trust created by a Will Others _______________________________________ [please specify]

(Note: ^Details of holding/parent company should be provided where applicant/investor is a subsidiary of listed company) If ‘None of the above’ option is selected, the following information [Part III] shall be provided mandatorily as applicable

* If the given rows are not sufficient, applicant/investor can submit multiple declarations covering all Ultimate Beneficial Owners# Attached documents should be self-certified by the UBO and certified by the applicant/investor/authorized signatory (ies).

S No

Name of UBO[Mandatory]

PAN or any other valid ID proof for

those where PAN is not applicable #

[Mandatory]

Position / Designation[to be provided

wherever applicable]

Applicable Period UBO Code[Mandatory]

[Refer instructions E]

KYC (Yes/No)[Please attached KYC

acknowledgement copy]

44

1. Ultimate Beneficiary Owner [UBO]:

A. For Investors other than individuals or trusts:

(i) The identity of the natural person, who, whether acting alone or together, or through one or more juridical person, exercises control through ownership or who ultimately

has a controlling ownership interest. Controlling ownership interest means ownership of/entitlement to:

- more than 25% of shares or capital or profits of the juridical person, where the juridical person is a company;

- more than 15% of the capital or profits of the juridical person, where the juridical person is a partnership;

- more than 15% of the property or capital or profits of the juridical person, where the juridical person is an unincorporated association or body of individuals.

(ii) In cases where there exists doubt under clause (i) above as to whether the person with the controlling ownership interest is the beneficial owner or where no natural person

exerts control through ownership interests, the identity of the natural person exercising control over the juridical person through other means like through voting rights,

agreement, arrangements or in any other manner.

(iii) Where no natural person is identified under clauses (i) or (ii) above, the identity of the relevant natural person who holds the position of senior managing official.

B. For Investors which is a trust:

The identity of the settler of the trust, the trustee, the protector, the beneficiaries with 15% or more interest in the trust and any other natural person exercising ultimate effective

control over the trust through a chain of control or ownership.

C. Exemption in case of listed companies / foreign investors

The client or the owner of the controlling interest is a company listed on a stock exchange, or is a majority-owned subsidiary of such a company, it is not necessary to identify

and verify the identity of any shareholder or beneficial owner of such companies. Intermediaries dealing with foreign investors' viz., Foreign Institutional Investors, Sub Accounts

and Qualified Foreign Investors, may be guided by the clarifications issued vide SEBI circular CIR/MIRSD/11/2012 dated September 5, 2012, for the purpose of identification

of beneficial ownership of the client.

D. KYC requirements

Beneficial Owner(s) is/are required to comply with the prescribed KYC process as stipulated by SEBI from time to time with any one of the KRA & submit the same to AMC. KYC

acknowledgement proof is to be submitted for all the listed Beneficial Owner(s).

E. UBO Codes:

UBO Code Description

UBO-1 Controlling ownership interest of more than 25% of shares or capital or profits of the juridical person [Investor], where the juridical person is a company

UBO-2 Controlling ownership interest of more than 15% of the capital or profits of the juridical person [Investor], where the juridical person is a partnership

UBO-3 Controlling ownership interest of more than 15% of the property or capital or profits of the juridical person [Investor], where the juridical person is an unincorporated

association or body of individuals

UBO-4 Natural person exercising control over the juridical person through other means exercised through voting rights, agreement, arrangements or in any other

manner [In cases where there exists doubt under UBO-1 to UBO-3 above as to whether the person with the controlling ownership interest is the beneficial owner

or where no natural person exerts control through ownership interests]

UBO-5 Natural person who holds the position of senior managing official [In case no natural person cannot be identified as above]

UBO-6 The settlor(s) of the trust

UBO-7 Trustee(s) of the Trust

UBO-8 The Protector(s) of the Trust [if applicable].

UBO-9 The beneficiaries with 15% or more interest in the trust if they are natural person(s)

UBO-10 Natural person(s) exercising ultimate effective control over the Trust through a chain of control or ownership.

For any queries/clarifications, please contact the nearest Customer/Investor Service Centres of the AMC. The list of our authorised centres is available in the section 'Contact

Us' on our website www.icicipruamc.com.

UBO - GENERAL INFORMATION AND INSTRUCTIONS

As per SEBI Master Circular No. CIR/ISD/AML/3/2010 dated December 31, 2010 regarding Client Due Diligence policy, related circulars on anti-money laundering and SEBI circularNo.CIR/MIRSD/2/2013 dated January 24, 2013, non-individuals and trusts are required to provide details of ultimate beneficiary owner [UBO] and submit appropriate proof ofidentity of such UBOs. The beneficial owner has been defined in the circular as the natural person or persons, who ultimately own, control or influence a client and/or persons onwhose behalf a transaction is being conducted, and includes a person who exercises ultimate effective control over a legal person or arrangement.

Part IV : Declaration

I/We acknowledge and confirm that the information provided above is/are true and correct to the best of my/our knowledge and belief. In caseany of the above specified information is found to be false or untrue or misleading or misrepresenting and/or the declaration is not provided,then the AMC/Trustee/Mutual Fund shall reserve the right to reject the application and/or reverse the allotment of units and the AMC/Trustee/Mutual Fund shall not be liable for the same. I/We hereby authorize sharing of the information furnished in this form with all SEBI RegisteredIntermediaries and they can rely on the same. In case the above information is not provided, it will be presumed that applicant is the ultimatebeneficial owner, with no declaration to submit. I/We also undertake to keep you informed in writing about any changes/modification to theabove information in future and also undertake to provide any other additional information as may be required at your end.

Authorized Signatories [with Company/Trust/Firm/Body Corporate seal]

__________________________ ____________________________ _______________________________

Date: ____ / ____ / ____

Place: ___________________

ashok

Typewritten Text

common application form application no. for...

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