REQUEST LETTER AND CUSTOMER APPLICATION FORM FOR

CONVERSION OF RESIDENT ACCOUNTS TO NRO

(To be submitted with photocopies of self-attested valid passport/relevant documentary proof of
all account holders as applicable)
Application number / Case ID: Sol ID: Employee ID:

Account number: Mode of Operation:

Primary applicant Name:

Joint Holder 1 Name:

Joint Holder 2 Name:

Mandate Holder Name:

Customer Annexures:

FATCA / CRS Declaration:

Under penalty of perjury, I/we certify that: 1. The applicant/s is/are (i) Taxable as a US person under the laws of the United States of America (U.S.) or any state or political subdivision
thereof or therein, including the District of Columbia or any other states of the U.S. (ii) An estate, the income of which is subject to U.S. federal income tax regardless of the source
thereof. (This clause is applicable only if the account holder/s is/are identified as a US person) or 2.The applicant/s is/are taxable as a tax resident under the laws of country outside
India. (This clause is applicable only if the account holder/s is/are a tax resident outside of India) (i) I/We understand that the bank is relying on this information for the purpose of
determining my/our status in compliance with Foreign Account Tax Compliance Act (FATCA)/Common Reporting Standard (CRS). The bank is not able to offer any tax advice on
FATCA/CRS or its impact. I/We shall seek advice from professional tax advisor for any tax questions. (ii) I/We agree to submit a new form within 30 days if any information or
certification on this form becomes incorrect. (iii) I/We agree that as may be required by domestic regulators/tax authorities the bank may also be required to inform reportable details
to CBDT or close or suspend my/our account/s. (iv) I/we certify that I/we have provided the FATCA /CRS information to the bank official to the best of my/our knowledge and believe
the certification is true, correct, and complete including the Taxpayer Identification Number / Functional Equivalent Number.

Signature/ Thumb Impression Signature/ Thumb Impression Signature/ Thumb Impression Signature/ Thumb Impression
of Primary Applicant of Joint Applicant 1 of Joint Applicant 2 of Mandate Holder

Blood relative declaration (if the address proof is in the name of a relative who is not an applicant to the account)
I/ We hereby solemnly declare that I stay with Mr. / Ms. The proof of my current
/ permanent address as mentioned on the account opening form is in the name of my Spouse / Brother / Sister / Parent (father / mother) / Child (daughter / son) and I am enclosing a
proof of relationship. I/ We, solemnly affirm that my/ our current / permanent address is as mentioned in the Account Opening Form. The information given is correct and nothing has
been concealed. I am aware that it is illegal and it is a criminal offence to deliberately furnish false information or suppress information. I undertake to be entirely responsible for any
loss/ expenses incurred by the bank on account of relying on my declaration.

Signature/ Thumb Impression

of Primary Applicant

Declaration by the Address Proof Holder:

I, the address proof holder solemnly affirm that I have no objection to allow the Primary Applicant to use my address for bank communication purposes. The said primary applicant
resides with me at my residential address for which I have provided a valid proof as per bank’s requirements. The information given above is correct and nothing has been concealed
and I am aware that it is illegal and it is a criminal offence to deliberately furnish false information or suppress information.

(Signature of address proof holder)

Signature mismatch verification

With reference to my documents and the application form I have submitted herewith, I request you to record with yourselves my specimen signature as given in the application form.
While the signature appearing in the document submitted as proof is different. This difference in signature is because

.
Customer Declaration/s:
Public Provident Fund(PPF) / Sukanya Samruddhi Yojana (SSY)
Please Note, in case there is a PPF/SSY Account opened by you:

a. If the date of opening of PPF/SSY Account is prior to date of becoming NRI then PPF Account will be converted to NRI status. You can contribute towards PPF /SSYAccount on non
repatriation basis. PPF/SSY Account shall be continued till maturity but extension of account is not allowed as per scheme rules

b. If the date of opening of PPF/SSY Account is later than the date of becoming NRI then PPF/SSY Account will be closed and no interest shall be payable from the date of opening of
PPF Account.

Note: Duly filled and signed Form No 2 required for SSY(Sukanya Samruddhi Yojana) Closure.

(Signature of primary applicant)

Client Declaration for Products and Services availed outside the home country <if applicable>
I/We hereby certify that I am/we are resident(s)/citizen(s) of documents relating to such product or service while in India and that I/we have availed of this product/facility/ service from
ICICI Bank Limited (”ICICI Bank”) while in India and executed by all. I/We hereby represent, warrant, agree and undertake on a continuing basis that: There are/shall be no legal or
regulatory prohibition or impediments, as per the laws of my/our home country, against my/our maintaining my/our relationship with ICICI Bank, including availing the
aforementioned products/facilities/services from time to time; In availing the aforementioned products/facilities/services from time to time I/we shall ensure that I/we are in full
compliance with all laws and regulation, including, without limitation, all applicable exchange control/taxation laws/regulations in my/our home country. I/We shall obtain all
necessary regulatory approvals, if required, in connection with any such transactions and shall promptly make all necessary regulatory reporting, as and when required, to the
relevant authorities in my/ our home country or any other country of residence where I/we may relocate to in future and I/we agree to furnish to ICICI Bank upon request copies of the
approvals/reports, if any.
All decisions to avail of the aforementioned products/facilities/services from time to time are/shall be my/our own independent decisions, and are not/shall not be made in reliance
on any views or opinions, if any, as may be expressed by ICICI Bank or its representatives from time to time, and are/shall be arrived at after personal analysis and careful
consideration of the risks, benefits, terms and conditions taking into account my/our investment objectives, financial situation and particular needs.

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I/We shall not use the products/facilities/services availed from ICICI Bank in any manner which may subject ICICI Bank to the laws and regulations, including but not limited to any
applicable tax laws of any country other than India.
I/We shall be solely responsible for complying with all laws and regulations applicable in my/our home country or any other country of residence where I/we may relocate in future,
with respect to the products/facilities/services availed from ICICI Bank.
I/We are aware that the products/facilities/services availed by me/us while in India may or may not be serviced by the offshore branches/representative offices/subsidiaries of ICICI
Bank located outside India. I hereby request ICICI Bank, its affiliates, representatives, associates, service providers and employees of ICICI Bank and its affiliates, to contact me by
telephone, or otherwise communicate with me from time to time in connection with servicing issues pertaining to the relationship which I have with ICICI Bank/its affiliates from time
to time. In addition to the above, ICICI Bank, its affiliates and representatives, associates, service providers and employees of ICICI Bank and its affiliates may contact me from time to
time by telephone, or otherwise communicate with me in connection with new products/services of ICICI Bank/its affiliates.
I/We shall indemnify ICICI Bank, its affiliates, representatives, employees and agents against all losses, costs, expenses, suits, damages whatsoever arising out of or in connection
with their assistance and their services that may be provided to me/us for availing the aforementioned products/facilities/services. I/We acknowledge that ICICI Bank relies on my/our
representations, warranties, undertakings and statements contained herein in, agreeing to establish/continue.

Declaration about existing relationships with the bank

If the resident account is inactive or dormant, the request for re-designation shall be treated as application to activate the account with the NRI status. All accounts where you are
the primary applicant will be redesignated to NRI we request you to submit the name deletion form for any other accounts in case you are not the primary applicant.
Upon receipt of customer's request for change in status to Non-resident in the accounts, the existing deliverables like International Debit Cards shall be hot listed and new ATM
card/domestic Debit Card shall be reissued. The customer may continue using the existing cheque book.
In case of change in address in the account, documentary proofs for the same have to be submitted as per the prevailing bank policy subject to revision from time to time. The
overseas address proof is mandatory for the primary holder.
In case the difference of address in the form / resident account and the proof submitted the address shall be updated as per the documentary proof submitted.
After re-designation of account into NRO, the TDS rate on interest offered on such deposits shall be as per NRO guidelines.
All the holders who have become NRIs need to submit the KYC documents as per NRI KYC policy at the time of re-designation to NRO. Customer needs to provide the date of
becoming an NRI, in the absence of which the date of execution of request shall be recorded as date of conversion.
The Customer shall automatically be registered for the Internet Banking service provided by the Bank if the Customer was not a registered user of the Internet Banking services
as a resident. The relevant Internet Banking terms and conditions shall be applicable to the Customer.
The mode of operation on the existing account will be carried forward to the NRI account post conversion unless there is a resident joint holder in the account. In such cases the
mode of operation would be changed to Former or Survivor.
PM Schemes like Atal Pension Yojana (APY), Pradhan Mantri Jeevan Jyoti Bima Yojana (PMJJBY), Pradhan Mantri Suraksha Bima Yojana (PMSBY) will cease to be in effect since
non-residents are ineligible for these schemes
Recurring Deposits (RDs) and iWish RDs will be pre-maturely closed and credited to the converted NRO Savings Account
Existing nomination will continue for the existing NRO Savings Account
The bank account will be delinked from my existing Trading Account, if any please fill the delinking form.
Existing Fixed Deposit(s) shall be converted to NRO Fixed Deposits. Fixed Deposit Receipts issued, if any, will be null and void.
A fresh NRE Account would also be opened under the same Customer ID.
In case you are a joint holder in a resident savings account, your name will be deleted from that particular resident account. (If the primary holder of this joint account has also
become an NRI, please ask them to raise a Request for Conversion of Savings Account to NRO Account.
Public Provident Fund accounts should be closed immediately if the customer status is changed to Non Resident Indian.
Quantum Optima(QO) facility that is provided in your Saving Account wherein surplus balance above defined threshold limit is transferred to a Fixed Deposit through
Automatic sweep facility shall be discontinued, if valid PAN is not provided while conversion to NRO account.
Account should not be in debit balance
SBONL - Savings Bank - Online KIT to SBNRO Account cannot be converted
We will convert your current account and in case you wish to close the current account fill the closure account form
NCCT country declaration: I hereby confirm that all details submitted above are true and verified and in case of any due diligence requirement will provide documentary
evidence to bank ( Eg: Latest Salary Slip if customer is employed OR ii) if self-employed then provide Last audited Financial Statement)
Duly filled & signed Close relative declaration required to accept address proof of joint holder with acceptable list of Relationship proof document

GENERAL UNDERTAKINGS AND DECLARATIONS

These undertakings and declarations (as contained below) shall be in addition to and not in derogation of the Electronic Conversion Form (as defined below) and the Terms and
Conditions (as defined below and on the website www.icicibank.com) shall be construed as forming part of the Terms and Conditions.
I/We have authorised an employee of ICICI Bank Limited having Employee ID to enter the account opening details on my/our behalf and as per the instructions given by me in the
electronic conversion form.
i) The term "application form" denotes the electronic conversion form and customer application form. I/ We have reviewed and verified the details entered by him/her in the
electronic application form and declare the same to be true, correct and updated and the reference number mentioned above with respect to the electronic application form has been
generated by ICICI Bank post my review, verification and confirmation of the application details. The electronic application form and physical confirmation form together shall
constitute account opening documents for the above referred savings bank account. ii) I/We agree and confirm that in the event of inconsistency between the account opening
documents and the KYC documents provided by me/us, ICICI Bank, at its sole discretion, shall have the right to update the information in accordance with the KYC documents without
any prior notice to me/us. iii) I/We hereby declare that I am/we are "NRI/s" or PIO/s. ("PIO/s") as defined under the Foreign Exchange Management Act, 1999 & 2016 and the applicable
regulations, rules, notification, direction or order made thereunder (collectively, "FEMA"). I/We further agree and undertake that the attached photograph(s) is / are the true and up-to-
date evidence of my/our identity(ies).
iv) I/We understand and agree that Customer Application Form can be rejected by ICICI Bank for any reason whatsoever at its sole discretion and shall decline any instructions issued
by me/us, if any. I/We understand and agree that the Bank may contact me/us for further information and/or documents for verification of any and all information provided/ furnished
by me/ us.
v) I/We further declare and undertake that any transaction involving foreign exchange hereunder shall not involve, and shall not be designed for the purpose of any contraven-tion
or evasion of the provisions of FEMA and/ or any other laws applicable to NRIs/ PIOs for account(s).
vi) I/We hereby undertake to intimate ICICI Bank on my/our return to India for permanent residence immediately on arrival. I/We also undertake to abide by FEMA and close any of the
above-mentioned account (s) (maintained and/ or operated by me/ us in my/ our capacity of an NRI/PIO (as applicable)) on my/our becoming a resident Indian or convert the above
account(s) to a resident account wherever such conversion is possible at ICICI Bank's end. vii) I/We hereby undertake and confirm that I/ we have read and understood and hereby
agree to the terms and conditions as provided under/ made available to me/ us at ICICI Bank's website, www.icicibank.com/nri (the "Website") in respect of all products, services and
channels provided/ offered by ICICI Bank to me/us as NRIs/ PIOs (the "Terms and
Conditions").I/ We understand that the Terms and Conditions are subject to amendment from time to time and I/we shall keep myself/ ourselves updated with the updated Terms and
Conditions.
viii) I/We undertake, agree and confirm
a) That any and all information/details/ data/ documents etc. provided by me/us (including PAN details/ Form 60/61, nomination details, FATCA declaration etc.) shall be accurate, up
to date, genuine, true and correct in every manner whatsoever.
b) That I/ we are not and have not had any insolvency, bankruptcy or similar proceedings initiated against me/ us nor have I/we ever been adjudicated insolvent.
c) That I/ we have read the Application Form, the Terms and Conditions, Website information and brochure and I/ we am/ are aware of all the terms and conditions of availing finance
or service or products from ICICI Bank.
d) That my /our accounts /loan /investment credit facility shall be governed by the applicable laws and regulations and also the policy of ICICI Bank, which may be in force from time
to time. ICICI Bank or its agents to make references and enquiries related to information in this Application Form which ICICI Bank or its agents consider necessary for the purposes of
account (s) opening, verification with respect to "KYC" and/ or "AML".
e) To notify ICICI Bank regarding any change in my/our residence / employment address, contact number and e-mail ID for communication as stated in the Customer Application
Form, and provide any other information that ICICI Bank may require from time to time. In case I/ we fail to update the communication address, ICICI Bank disclaims all liabilities
resulting from any loss or damage caused to me/ us due to failure and/ or delay in the delivery of the I-Kit. ICICI Bank to exchange, share or part with all the information relating to my /
our accounts, transactions, or dealings with/ to other ICICI Bank, its group companies (including any affiliates and subsidiaries) / banking financial institutions / credit
bureaus/agencies

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/ statutory bodies, wherever located (including any disclosure of my/ our information to any national or local governmental or regulatory or statutory or judicial authorities and any
agent or contractor engaged to perform services for ICICI Bank's benefits) for the purposes of administration of my/our account and facilities extended to me/us hereunder, as may be
required under applicable laws and regulations and I/ we shall not hold ICICI Bank or its group companies/ subsidiaries or affiliates liable for use of any such information.
x) We (ICICI Bank limited, it's group companies, agents/ representatives) would like to keep our customers updated on the latest marketing offers. Please help us to serve you better
by giving your consent to receive such information. xi) ICICI Bank to use my/our information to administer my/our account(s) and for other business purposes including credit,
address verification, or in relation to compliance with any AML/KYC. xii) I/We consent / do not consent to receive such information through SMS alerts. I/We consent / do not consent
to receive such information through phone calls. I/We consent / do not consent to receive such information through e-mail alerts. I/We agree that no claim will be made by me /us for
any interest on any deposit/s for any period after date/s of maturity of the deposit/s except as provided by RBI under the regulations for such products/deposits availed. I / We shall not
make available to any person resident in India, foreign currency against reimbursement in "INR" or any other manner in India. I/We understand and acknowledge that in case I/we
instruct ICICI Bank for any conversion of my/our remittance/s from one currency to another, either for booking of a deposit or for such other permissible purposes as permitted under
FEMA, the currency conversion risk shall solely be borne by me/us. xiii) I /We would confirm that all debits to my / our accounts for the purpose of investment in India and credits
representing sale proceeds of investments in India are covered either by general or special permission of the RBI. xiv) I /We authorise ICICI Bank to issue an ICICI Bank Debit cum ATM
Card, Internet Banking and Phone Banking services to me/us. I/We acknowledge that the usage of the aforementioned services is governed by their respective terms and conditions
as amended from time to time. x) I / We further unconditionally and irrevocably authorise ICICI Bank to debit my/our account annually with an amount equivalent to the fees and
charges for use of the Debit Card. xi) I/We understand that to revoke the usage of the above services, I/We shall have to issue a letter of revocation ("the revocation letter") to ICICI
Bank in this regard. I/We hereby agree that until ten days after receipt of such revocation letter, the authorisation as aforestated shall hold good. The Terms and Conditions of Debit
Card- Member agreement governs the use of my /our card(s). xvii) I/We hereby confirm that all accounts under this Customer ID are operated singly and in case of joint account
operated by either or survivor /anyone or survivor(s). We joint holder/s, hereby authorise the First holder, to access the Internet Banking, Phone Banking and Mobile Banking channels
as provided for the first holder. I/We joint holder/s, hereby state that should I/we, Joint holder/s, wish to revoke the above authorisations:
I/We have received a copy of tariff guide. I/We have read and understood the contents of the brief Schedule of Charges provided in Tariff guide and detailed Schedule of Charges as
set forth on the Website and agree to abide by the same, subject to changes made thereto by ICICI Bank from time to time. I/ We agree that for the purposes of insurance cover in
relation to my/ our accounts, my personal information (as provided by me during the account opening process) and account number will be shared with the insurance provider. This
will be used to verify my identity in case of any claims.
Due to regulatory restrictions in certain countries and ICICI Bank's policies, insurance cover may not be provided/ made available in all jurisdictions/ geographies. Insurance cover is
provided by ICICI Lombard. I/We understand and agree that depending on my current or permanent country of residence, free Insurance cover might not be available to me/us at all
times. I/ We have read other terms and conditions of NRI Premia Account and other products and services specific terms and conditions available and updated on the Website from
time to time and I/ we agree to abide and be bound by them. In case of Bangladesh or Pakistan Citizens, I/we have obtained specific approval from RBI to open the accounts for NRIs
and a copy of the same has been submitted along with my/ our Application Form. As per the revised KYC process, if the communication sent to my declared current overseas is not
delivered, I understand and agree that the Bank shall take the necessary action on my account as it deems fit which may include closure of my account. Politically Exposed Persons
("PEP/s"): Politically Exposed Persons are individuals who are or have been entrusted with prominent public functions in a foreign country. Examples of PEPs include, but is not
limited to: (i) Heads of States or of Governments (ii) Senior politicians (iii) Senior government /Judicial /Military officers (iv) Senior executives of state owned corporations (v)
Important political party officials (vi) Senior Indian Diplomatic posted outside the country.
The term PEP also includes the families and close associates of the PEPs mentioned above. Families: The term families includes close family members such as spouse, children,
parents and siblings and may also include other blood relatives and relatives by marriage. Close associates: The term close associates in the context of PEPs includes close business
and personal advisors /consultants to the PEP as well as persons who benefit significantly from being close to such a person.
We hereby authorise the Bank to allow premature withdrawal(s) of the fixed/term deposit having operating instructions as 'Either or Survivor', in accordance with the operating
instructions of the deposit. We hereby further authorise and permit the Banks to allow premature withdrawal of the deposit by the surviving joint depositor on the death of the other
having operating instruction of "Either or Survivor" or "Former or Survivor", subject to execution of documents to the satisfaction of the Bank. Any such repayment before maturity
shall constitute a valid discharge of the Bank's obligations against all concerned including but not limited to the nominee / legal heirs of the depositors or anyone claiming under them.
Money2India DECLARATION
I hereby authorise ICICI Bank to use any / all information, as contained in this Customer Application Form, for the purpose of registering on Money2India services on my behalf.
I understand that Money2India Account is a default service offered to me with NRI Account and is currently being offered in U.S.A, Canada, United Kingdom, Singapore, Hong Kong,
Australia, Sweden, Switzerland and U.A.E, and may be extended to other geographies as updated on ICICI Bank's website from time to time. If I wish to opt out of the Money2India
services, I will write to nri@icicibank.com from my registered Money2India e-mail ID stating the same.
I/We hereby authorise ICICI Bank UK PLC (wholly owned subsidiary of ICICI Bank) to use any /all information, as contained in this application form, for the purpose of opening
Money2India Europe Account on my/our behalf. I/We understand that Money2India Europe Account is a default service offered to me/us with NRI account and is currently being
offered in 20 countries in Europe and zmaybe extended to other geographies as updated on Money2India Europe website from time to time. Money2India Europe Account is a
service offered by ICICI Bank UK PLC, Germany Branch. For more information, please visit www.money2india.eu.
I/We hereby undertake that any or all documents submitted by me/us to the Bank (including through e-mail, logged-in section, scanned image) shall be considered as duly executed
and authorised by me/ us. I/We hereby authorise the Bank to rely on such documents and agree not to hold the Bank liable for any losses that may arise out of the Bank's reliance on
such documents.

Signature/ Thumb Impression Signature/ Thumb Impression Signature/ Thumb Impression

of Primary Holder of Joint Holder 1 of Joint Holder 2

Branch Declaration/s:
Payment Details
I hereby tender Currency Amount towards deposits in NRI Savings Account by,
Cash (Please make payment in cash only at the branch, cash payments are not permitted outside the branch premises.)
Cheque / Demand Draft Number Currency Amount
drawn on bank
Branch confirmation for Cash deposit: Cashier’s signature Employee ID

Signatures and Branch KYC Certification

Name and Designation of the Bank Official authorising the opening of the account
Date: Employee ID:

(Signature of Bank Official with Seal)

I have met Mr/ Ms/ Mrs/ Dr. &
&
& in persons at their
residence /office
others
and confirm that I have verified the copies of the KYC documents (as applicable) against originals as produced by the applicant. I also confirm that the form has been signed by
the applicants in my presence.
Mandate and Nomination
Mandate Declaration
Mandate Holder Name: Dr. Mr. Ms.

NRE Savings Account number: NRO Savings Account number:

$ $ $

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(I) I / We hereby authorise the mandate holder a) to draw cheques on the account for local payments b) to deposit cheques eligible to be deposited in the NRE Account on behalf of
the Account holder(s), as permitted by RBI regulations c) to make NRE Fixed Deposits from balances available in the account in account holder(s) names under the same Customer ID
and renew such deposits for such periods as may be given in writing by the mandate holder d) to operate the account to facilitate making investments in
India, applicable wherein the account holder(s) or a bank designated by the account holder(s) is eligible to make investments in India
(II) I/ We authorise ICICI Bank Ltd. to issue an ICICI Bank ATM card and a cheque book to the mandate holder. I / We and the mandate holder acknowledge that the issue and usage of
the card is governed by the terms and conditions as in force from time to time and agree to be bound by the same. I / We and the mandate holder acknowledge that it is my / our
responsibility to obtain a copy and read the same. I / We and the mandate holder accept that the terms and conditions are liable to be amended by ICICI Bank Ltd. from time to time.
I/We further unconditionally and irrevocably authorise ICICI Bank Ltd., to debit my / our account annually with an amount equivalent to the fees and charges for the use of the said
ATM card if any. (III) I / We declare that as per RBI guidelines
a) the mandate holder can exercise the authority conferred by this letter to withdraw for local payments only, and make investment in India where I / we hold general permission or
have obtained specific permission from RBI. b) the mandate facility permits the mandate holder to remit funds in foreign currency to the account holder(s). I / We hereby undertake
that I / we and my/ our mandate holder shall comply with the provisions of the RBI guidelines, and the Foreign Exchange Management Act, 1999 and all regulations thereof, including
the Foreign Exchange Management (Deposit) Regulations, 2000 and I / we hereby undertake that I / we have made known to the mandate holders the specific uses of the ATM Card as
per the said Regulations and Guidelines. I / We hereby undertake to indemnify ICICI Bank against any loss, damage, claim, action, proceedings, costs, charges and expenses that may
be suffered or incurred by ICICI Bank on account for any activity undertaken by the mandate holder by the use of the ATM Card. Foreign Exchange Management (Deposit)
Regulations, 2016
(IV) The specimen signature of the mandate who has been authorised to operate upon the account is given below and on the third page of the form. The signature has been duly
attested and verified by me/us.
(V) This authority shall continue in force until I / we shall have expressly revoked it by a notice in writing delivered to you. I have read and understood all the conditions stated above
and hereby agree to comply with same

Signature/ Thumb Impression Signature/ Thumb Impression Signature/ Thumb Impression Signature/ Thumb Impression
of Primary Holder of Joint Holder 1 of Joint Holder 2 of Mandate Holder

Nomination

Carry forward existing nomination

Modify nominee

Add nominee and delete existing nominee

I / We
Address
of the depositor(s) nominate the following person (details provided hereunder) to whom in the event of my/our death the amount of deposit in the account, particulars whereof
are given below, may be returned by ICICI Bank Limited, Branch
(name and address of branch in which deposit is held).
Nominee’s Name: Mr./Ms./Dr.

Date of Birth of nominee: House No./Building Name :

City: PIN: Tel. No.:

Relationship with applicant: Age:

Street:

Country:
(please specify if other than India)

As the nominee is a minor on this date, I/we appoint

Age to receive the amount of the deposit on behalf of the nominee in the event of my/our/minor’s death during the minority of the nominee.

Mandatory for Minor Nominee

Relation with Nominee

House No./ Building Name

Tel. No.: Area code

Street: City

State: PIN:

Country
(please specify if other than India)

Signature/ Thumb Impression Signature/ Thumb Impression Signature/ Thumb Impression

of Primary Holder of Joint Holder 1 of Joint Holder 2

Nomination under Section 45ZA of the Banking Regulation Act, 1949, and rule 2 (1) of the Banking Companies (Nomination) Rules, 1985, in respect to bank deposits. I have
been explained about the benefits of the nomination facility. However, I do not wish to provide nomination for the Account.

(Signature of primary applicant)

$ $ $

Nomination Acknowledgement

I. We acknowledge receipt of nomination made by you in favour of:

Name of the nominee Age:
II. No nominee registration of the account since nomination facility not availed by the account holder.
III. According to the RBI’s nomination guidelines, it is necessary to register a nominee for account opened under a single name. Appointing a nominee is beneficial for the
following reasons
1) If the account holder dies, the bank can quickly send the funds to the account of the nominee.
2) Hassle-free formalities for the nominee while claiming benefits.
3) Nomination can save time, energy and money.
4) Branch official to fill track id or SR number. (Signature of Bank Official with Seal)