ICICI Bank Limited, CPC-Demat Services, Ground Floor, B-Wing, Autumn Estate, Chandivali Farm Road, Opp.

Mhada Colony, Chandivali, Andheri (East), Mumbai - 400072.

Date D D M M Y Y Y Y DP ID Client ID

DRN No.
(to be filled-in by the DP)

1. I/We wish to inform that my/our signature in the records of Issuer or RTA may vary from the signature as captured in my/our
demat account (Details of which have been mentioned in Dematerialisation Request Form).

2. My/our signature/s might have changed/altered by passing of time and therefore I/we request you to forward this form to the
Issuer/RTA alongwith the Demat Request Form to facilitate the Issuer/RTA to process the dematerialisation.

SIGNATURE WITH ISSUER/RTA SIGNATURE WITH ISSUER/RTA SIGNATURE WITH ISSUER/RTA

OF SOLE/FIRST HOLDER OF SECOND HOLDER OF THIRD HOLDER