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

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

(to be given by legal heir(s) when nomination has not been made)

(Date) (Deceased) (Deceased)

Sole/First Holder:
(Name of the First Holder as updated in Demat account)
Second Holder:
(Name of the Second Holder as updated in Demat account)
Third Holder:
(Name of the Third Holder as updated in Demat account)

I son/daughter/spouse of
(Name of Claimant) (Deceased name)
residing at do hereby
(Address of Claimant)
solemnly affirm on oath and state as under :

1. That Mr./Mrs. the deceased, was holding a Client account no. with
(Deceased name) (Deceased) (ICICI)
a Depository Participant having DP Id . The said deceased was holding the following securities :
(in Deceased)

(ISIN Details) (Mention the ISIN each Annexure to be attached in care of more than 4 ISIN)

2. That the deceased had died intestate on at .

(Date) (Place)
3. That the following are the only legal heir(s) of late Mr./Mrs.
(Deceased name)

Name Address Age Relationship with

(Name of the Claimant & NOC Giver) the deceased
1.
2.
3.
4.

4. That out of aforesaid legal heirs Master/Kum aged years is a minor and he/she is
(to be filled only in case of minor claimant)
being represented by his/her father/mother and natural guardian Mr./Mrs.

5. That all the legal heirs of my deceased have applied to (DP name) to
(name of Deceased ) (ICICI Bank )
register the aforesaid securities in my/our individual/joint beneficial owner account and have execute a Letter of Indemnity in favour of the
Participant/NSDL holding the Participant/NSDL indemnified against any loss, cost, expenses or damages which may be caused to them

in consequence of any claim which may be made by or on behalf of any person claiming any interest in the said shares.

Applicant/Deponent Signature
(Signature of Claimant)
 (to be given by legal heir(s) when nomination has not been made)

I hereby solemnly affirm and say that what is stated herein above are true to my knowledge and nothing has been concealed therein and that I am
competent to contract and entitled to rights and benefits of the above securities.

Solemnly affirmed at on the day of of .

(Place) (Date)

Full Name and :

Address of
Applicant/Deponent Signature
Magistrate/ (Magistrate Person Name
signed in the presence of
Magastrate / Notary
(Signature of Claimant))
Notary
Pincode of Magistrate)
Pincode

Regd. No.

(Signature of Magistrate/Notary)
(Notary Signature ))

Use space below to affix :

(Magistrate Person Name Magastrate / Notary inside box Pincode of Magistrate)

1. This affidavit is to be executed in the presence of a first class or stipendiary Magistrate/Public notary / Judicial.
2. This affidavit should be signed by each deponent separately.