COMMON APPLICATION FORM FOR 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.

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.

BROKER CODE (ARN CODE)/

RIA CODE#

SUB-BROKER ARN CODE

Employee Unique

Identification No. (EUIN)

SUB-BROKER CODE

(As allotted by ARN holder)

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

• In case the purchase/subscription amount Rs 10,000/- or more and your Distributor has opted to receive transactions charges, the same are deductible as appli-

cable from the purchase/subscription amount and paid 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.

TRANSACTION CHARGES FOR APPLICANTS THROUGH DISTRIBUTORS ONLY [Refer Instruction XII]

MANDATORY

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

9 Digit

MICR Code

11 Digit

IFSC

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.

Enclosed (Please ):

Bank Account Details Proof Provided.

Account

Number

Account Type

Savings

Name & Branch

of Bank

Branch City

Current

NRE

NRO

FCNR

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 advice by the employee/relationship manager/sales person of 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 advisory fees on this transaction.

#By mentioning RIA code, I/we authorize you to share with the Investment Adviser the details of my/our transactions in the scheme(s) of ICICI Prudential Mutual Fund.

3. INVESTMENT DETAILS (Refer Instruction No. IV)

(For Plans & Sub-options please see key scheme features). Please mention scheme name below:

4. PAYMENT DETAILS

DD Charges

(if applicable)

A + B

Total

Amount

Mode of Payment Cheque

Funds Transfer

NEFT

RTGS

Cheque /

DD Number

Investment

Amount

BANK DETAILS:

Same as above [Please tick () if yes]

Different from above [Please tick () if it is different from above and ﬁll in the details below]

Cheque

Copy

Mandatory Enclosures (Please tick ()

if the ﬁrst instalment is not through cheque)

Bank

Statement

Banker’s Attestation______________

________________________________

Name & Branch

of Bank

Branch City

A/c Number

Account Type

D D M M

Y YY Y

Date

Savings

Current

NRE

NRO

FCNR

ICICI Prudential _____________________________________________________________ Plan: _______________________ Option: ________________________

Existing Folio No.

ACKNOWLEDGEMENT SLIP

(Please Retain this Slip)

Application No.

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

EXISTING FOLIO NO.

Name of the Investor:_____________________________________________________________

Please tick () if you wish to receive Annual Report or Abridged Summary via Post - (Default communication mode is E-mail) [Refer Instruction No.IX(a)]

Please tick () if you wish to receive Account statement / Other statutory information via Post instead of Email [Refer Instruction No.IX(b)]

Please

 any of the frequencies to receive Account Statement through e-mail

: Daily Weekly Monthly Quarterly Half Yearly Annually

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

** Mandatory in case the Sole/First applicant is minor and/or if investing in Retirement

Fund.

For KYC requirements, please refer to the instruction Nos. II b(5) & X

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

Correspondence Address (Please provide full address)*

Overseas Address (Mandatory for NRI / FII Applicants)

5. CORRESPONDENCE DETAILS OF SOLE/FIRST APPLICANT:

HOUSE / FLAT NO.

STREET ADDRESS

COUNTRY PIN CODE

HOUSE / FLAT NO.

STREET ADDRESS

PIN CODE

CITY / TOWN STATE

COUNTRY

CITY / TOWN STATE

Tel.

Office Residence

Mobile

TOLL FREE NUMBER: 1800 222 999 (MTNL/BSNL) 1800 200 6666 (OTHERS) EMAIL: enquiry@icicipruamc.com WEBSITE: www.icicipruamc.com

NAME OF GUARDIAN

(in case First/Sole applicant is minor)

/CONTACT PERSON-DESIGNATION/PoA HOLDER

(in case of Non-Individual Investors)

If mandatory information left blank, the application is liable to be rejected. ¥

Individual client who has registered under Central KYC Records Registry (CKYCR) has to fill the 14 digit KYC Identification Number (KIN).

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

(Name should be as per the PAN)

SOLE / 1

APPLICANT

Mr. Ms. M/s FIRST MIDDLE LAST

APPLICANT

Mr. Ms. M/s FIRST MIDDLE LAST

Mr. Ms. FIRST MIDDLE LAST

Enclosed (Please )

§*

KYC Acknowledgement Letter

PAN/PEKRN*

KYC Id No.

Date of Birth**

DDMMYYYY

Relationship with Minor applicant:

Natural guardian Court appointed guardian

Date of Birth

D D M M Y Y Y Y

PAN/PEKRN*

KYC

Id No.

KYC Proof Attached (Mandatory)

Date of Birth

D D M M Y Y Y Y

KYC Proof Attached (Mandatory)

PAN/PEKRN*

KYC Id No.

Date of Birth

D D M M Y Y Y Y

KYC Proof Attached (Mandatory)

PAN/PEKRN*

KYC Id No.

QFund.in Mutual Fund India

Mutual Fund

India

Mutual Funds

Mutual Fund

India

Mutual Fund

India

Annexure I and Annexure II are available on the website of AMC i.e. www.icicipruamc.com or at the Investor Service Centres (ISCs) of ICICI Prudential Mutual Fund.

Country of Tax Residency

Tax Identification Number or

Functional Equivalent

Identification Type

(TIN or other please specify)

If TIN is not available please tick ()

the reason A, B or C (as defined below)

Reason : A

B C

Reason : A B C

9. FATCA AND CRS DETAILS FOR INDIVIDUALS (Including Sole Proprietor) (Mandatory)

Non-Individual investors should mandatorily ll separate FATCA Form (Annexure II). The below information is required for all applicants/guardian

First Applicant / Guardian

Second Applicant

Third Applicant

First Applicant / Guardian

Second Applicant

Third Applicant

Place/City of Birth Country of Citizenship / Nationality

Are you a tax resident (i.e., are you assessed for Tax) in any other country outside India? Yes No [Please tick ()]

If ‘YES’ please fill for ALL countries (other than India) in which you are a Resident for tax purpose i.e. where you are a Citizen/Resident / Green Card Holder / Tax Resident in the respective countries.

10. KYC DETAILS (Mandatory)

Occupation [Please tick ()]

Private Sector Service

Public Sector Service

Government Service

Business

Professional

Agriculturist

Retired

Housewife

Student

Forex Dealer

Others (Please specify)_______________________________________________

Private Sector Service

Public Sector Service

Government Service

Business

Professional

Agriculturist

Retired

Housewife

Student

Forex Dealer

Others (Please specify)_______________________________________________

Private Sector Service

Public Sector Service

Government Service

Business

Professional

Agriculturist

Retired

Housewife

Student

Forex Dealer

Others (Please specify)_______________________________________________

Sole/First

Applicant

Second

Applicant

Third

Applicant

Gross Annual Income [Please tick ()]

Sole/First Applicant

Below 1 Lac

1-5 Lacs

5-10 Lacs

10-25 Lacs

>25 Lacs-1 crore

>1 crore

OR Net worth (Mandatory for Non-Individuals) ` ___________________________ as on (Not older than 1 year)

Second Applicant

Third Applicant

Below 1 Lac

1-5 Lacs

5-10 Lacs

10-25 Lacs

>25 Lacs-1 crore

>1 crore OR Net worth ` ________________________________

Below 1 Lac

1-5 Lacs

5-10 Lacs

10-25 Lacs

>25 Lacs-1 crore

>1 crore OR Net worth ` ________________________________

D D M M Y Y Y Y

Others [Please tick ()]

For Non-Individuals [Please tick ()] (Please attach mandatory Ultimate Beneficial Ownership (UBO) declaration form - Refer instruction no. IV(h)):

For Individuals [Please tick ()]:

I am Politically Exposed Person (PEP)

I am Related to Politically Exposed Person (RPEP)

Not applicable

(i) Foreign Exchange / Money Changer Services –

YES

NO; (ii) Gaming / Gambling / Lottery / Casino Services –

YES

NO; (iii) Money Lending / Pawning –

YES

Sole/First

Applicant

Second Applicant

Politically Exposed Person (PEP)

Related to Politically Exposed Person (RPEP)

Not applicable

Third Applicant

Politically Exposed Person (PEP)

Related to Politically Exposed Person (RPEP)

Not applicable

Indian

U.S.

Others (Please specify) _____________________

Country of Birth

q Reason A _ The country where the Account Holder is liable to pay tax does not issue Tax Identification Numbers to its residents.

q Reason B _ No TIN required (Select this reason Only if the authorities of the respective country of tax residence do not require the TIN to be collected)

q Reason C _ Others, please state the reason thereof: _________________________________________________________________________________________________

Address Type of Sole/1st Holder:

Residential Registered Office Business

Address Type of 2nd Holder:

Residential Registered Office Business

Address Type of 3rd Holder:

Residential Registered Office Business

11. NOMINATION DETAILS (Refer instruction VII). I/We hereby nominate the undermentioned nominee(s) to receive the amount to my/our credit in event of my/our death as follows:

Name and address of Nominee(s)

Date of Birth Name and address of Guardian

[To be furnished in case the Nominee is a minor (Mandatory)]

Signature of Nominee/

Guardian, if nominee is a minor

Proportion (%) in

which the units will

be shared by each

Nominee (Should

aggregate to 100%)

Nominee 1

Nominee 2

Nominee 3

Applicant’s

Relationship

with the

Nominee

(Please tick if Nominee’s address is

same as 1st/Sole Applicant’s address)

INVESTOR(S) DECLARATION & SIGNATURE(S): To the Trustee, ICICI Prudential Mutual Fund, I/We have read, understood and hereby agree to abide by the Scheme Information

Document/Key Information Memorandum of the Scheme(s), Foreign Account Tax Compliance Act (FATCA) and Common Reporting Standards (CRS) under FATCA & CRS provision of the Central Board of

Direct Taxes notified Rules 114 F to 114H,as part of the Income-tax Rules,1962. I/We apply for the units of the Fund and agree to abide by 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 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, 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 of any 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 corpus of 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/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 recommended to me/us. I/We interested in receiving promotional

material from the AMC via mail, SMS, telecall, etc. I/we declare that the email address provided in the form belongs to me/us or to spouse, dependent children or dependent parents (applicable

to individual investors only). If you do not wish to receive, please call on tollfree no. 1800 222 999 (MTNL/BSNL) or 1800 200 6666 (Others).

Scheme Name Plan Option/Sub-option Payment Details

Amt. _____________________ Cheque/DD No. ___________________________ dtd._______________________

Bank & Branch_________________________________________________________________________________

6. MODE OF HOLDING [Please tick ()]

Single

Joint

Anyone or Survivor (Default)

7. TAX STATUS [Please tick ()]

Resident Individual NRI Partnership FIRM Government Body FPI category I NPS Trust Bank

On behalf of Minor Foreign National Company AOP/BOI FPI category II NON Profit Organization/Charities

HUF Body Corporate Private Limited Company Public limited company FPI category III Defence Establishment

Financial Institution Trust/Society/NGO Limited Partnership (LLP) Sole Proprietorship Others (Please specify) ___________________________________

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

CDSL: Depository Participant (DP) ID (CDSL only)

NSDL: Depository Participant (DP) ID (NSDL only)

Beneficiary Account Number (NSDL only)

Sole/1st

Applicant

2nd

Applicant

3rd

Applicant

Mutual Fund India

Mutual Fund

India

Mutual Fund

India

Mutual Funds

Mutual Fund

India