Third Party Payment Declaration Form printable pdf download

Investment Manager: ICICI Prudential Asset Management Company Limited

Regd. Office: 12th Floor, Narain Manzil, 23, Barakhamba Road, New Delhi 110 001.

Corporate Office: 3rd Floor, Hallmark Business Plaza, Sant Dyaneshwar Marg, Bandra (East), Mumbai - 400 051,

Tel: (91) (022) 26428000, Fax: (022) 2655 4165.

Central Service Office: 2nd Floor, Block B-2, Nirlon Knowledge Park, Western Express Highway, Goregaon (East),

Mumbai 400 063. Tel: (91) (22) 26852000, Fax: (91)(22) 2686 8313.

Third Party Payment Declaration

(This should be enclosed with each payment/SIP Enrolment)

Payments by

: Parent/Grand-Parents/Related Persons Other than the Registered Guardian

Payments to

: To a Minor Folio only; In consideration of: Natural love and affection or as gift only

Maximum Value : Not Exceeding Rs 50,000/- (each regular purchase or per SIP installment)

Application

Folio

PAN

No.

(For existing unitholders only)

KYC Acknowledgement :

Attached

Beneficial Minor’s Name:

Mr. / Ms.

Investment Amount

Payment Cheque No.

Cheque Date

Cheque Drawn on A/c. No.

Cheque Drawn on Bank:

DECLARATION & SIGNATURES

Parent/Grand Parents/Related Persons

Guardian of Minor, as registered in the folio

other than the Registered Guardian

Name

Relationship with Minor:

IT PAN

KYC Acknowledgement

Attached

(Mandatory - any amount)

I hereby declare and confirm that the minor stated above is the

I confirm that I am the legal guardian of the Minor, registered

Declaration

beneficial owner of the investment details mentioned above and I

in folio and have no objection to receiving these funds on behalf

am providing the funds for these investments on account of my

of the minor.

natural love and affection or as gift from my bank account only.

Signature

Contact Number

Bankers Certificate in case of Demand Draft/Pay Order/Any Other pre-funded instrument:

To whomsoever it may concern, we hereby confirm the following details regarding the instrument issued by us:

Instrument Type:

Demand Draft

Pay Order

Instrument Number:

Dated:

Investment Amount:

In Favour of / Favouring:

Payable At:

Details of Bank Account Debited for issuing the instrument

Bank Account Number:

Account Type

}

Demand

Pay Order

Issued through

Yes /

Debit from account

Yes /

Draft

cash

(Cash shall not be accepted for investment of Rs.50,000/- or more)

Name

Income Tax PAN

Account Holder/Applicant

Details

If the issuing bank branch is outside India

We further declare that we are registered as a Bank/branch as mentioned below:

Under the Regulator

Name of Regulator

In the Country

Country Name

Registration No.

Registration Number

We confirm having carried out necessary Customer due diligence with regard to the Beneficiary and to the source of the funds received from him, as per the

standards of Anti-Money Laundering laws in our country.

Branch Manager/Declarant(s):

Signature: _________________________________________________________________________________________________________

Name: ___________________________________________________________________ Address: _________________________________

___________________________________________________________________________City ___________________________________

Bank & Branch Seal

Postal Code:_______________________ Country:___________________________________ Contact No.____________________________

Third Party Payment Declaration Form

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