Third Party Payment Declaration Form Page 2
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1
2
3Custodian on behalf of an FII or client:
Should be enclosed with each payment
To whomsoever it may concern
(All details below are mandatory)
Application and Payment Details
Folio No.
Application Form no.
Beneficial Applicant/
Investor Name:
Investment Amount
Payment Mode
Cheque
Funds Transfer
RTGS
NEFT
Payment Cheque /UTR No.
Dated:
D
D
M
M
Y
Y
Payment from Bank:
Payment from A/c No.:
We further declare that we are registered as a Custodian with SEBI under Registration No:
___________________________________________________________________
We confirm that the beneficial owner stated above and that this payment is issued by us in our capacity as Custodian to the Applicant/Investor. The source of this
payment is from funds provided to us by the Applicant/Investor.
Signature of Declarant(s): _______________________________________
________________________________________
_______________________________________
(Acting as a Banker/Custodian)
Name(s) of Declarant(s): __________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________
Income Tax PAN : ________________________________________
________________________________________
_________________________________________
Address of Declarant(s):___________________________________________________________________________________________________________________________
________________________________________________________________________________________ City __________________________________________________
Postal Code:_________________________ State: __________________________________________________ Country:____________________________________________
Payment by Employer on behalf of Employee under Systematic Investments Plans through Payroll deductions
To whomsoever it may concern
We hereby declare that the application form no: ________________________________________ for subscription of units in _______________________________________
________________________________________________________ (Name of the Scheme /Plan/ Option) is accompanied by cheque no: ____________________________
dated __________________________ drawn on ____________________________________________________________________________ (Name of the Bank / Branch).
We confirm that the beneficial owner(s) of the investment in these units is/are _____________________________________________________________________________
________________________________________________________________ (Name of the Employee, with employee number), who is my / our employee and am providing
the funds for these investments through the payroll deduction.
Signature of Declarant(s): _______________________________________
________________________________________
_______________________________________
Name(s) of the Declarant(s): _______________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________
Income Tax PAN : ________________________________________
________________________________________
_________________________________________
Address of Declarant(s): __________________________________________________________________________________________________________________________
________________________________________________________________________________________ City __________________________________________________
Postal Code:_________________________ State: _________________________________________________ Country:_____________________________________________
Signature(s) of Beneficiary(ies)
1. ______________________________________
2. ___________________________________
3. ___________________________________
Please refer to the instruction on the next page for the details on Third Party Declaration.
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