Mailing Address Declaration Form

Date:

To,

Citibank N.A.

______________________

______________________

Subject : Confirmation of mailing address (Residence/ Office) for account number ____________________________________________

I ____________________________________________________________ hereby confirm that following address is my residence/office

(name of the account holder)

address, and I request you to update the same as my mailing address.

Mailing address (Please provide full address)

___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

Further I confirm that I do not have any proof of the above mentioned current residence/mailing address address in my name due to

[Please specify reason] ______________________________________________________________________________________________

As I do not have any proof of mailing address in my name, I am submitting herewith, the address proof for my permanent address

Permanent address (Please provide full address)

___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

______________________________ ______________________________

[Name of first holder] [Signature of first holder]

______________________________ ______________________________

[Name of joint holder] [Signature of joint holder]

Citibank India does not market any product or service to individuals resident in the European Union, European Economic Area, Switzerland, Guernsey
and Jersey.
This is not, and should not be construed as, an offer, invitation or solicitation to buy or sell any of the products and services mentioned herein to
individuals resident in the European Union, European Economic Area, Switzerland, Guernsey and Jersey

This product/service is offered by branches of Citibank, N.A. in India. © 2018 Citigroup Inc. Citi and Arc Design are registered service marks of Citigroup Inc. or its
affiliates used and registered throughout the world. VER 1.0/BAN/MADF DOM/WPC/11-18