APPLICATION FORM NFO Opens : January 17, 2022

Please read instructions before filling this form MUT U AL F U N D

All sections to be completed in ENGLISH in BLACK /
NFO Closes : January 31, 2022
BLUE Coloured Ink and in BLOCK LETTERS.

Sponsor: Samco Securities Limited Samco Mutual Fund

Trustee Company: Samco Trustee Private Limited 1003 – A, Naman Midtown, Senapati Bapat Marg, Application No.
Investment Manager: Samco Asset Management Private Limited Prabhadevi (W), Mumbai - 400 013.

DISTRIBUTOR INFORMATION
Distributor Code Sub-Broker Code Internal Sub-Broker Code EUIN RIA CODE^
Employee Unique
ARN - ARN - INTERNAL CODE
IDENTIFICATION NO.
*Investors should mention the EUIN of the person who has advised the investor. If left blank, the fund will assume following declaration by the investor “I/We hereby confirm that
the EUIN box has been intentionally left blank by me/us as this transaction is executed without any interaction or advice by the employee/relationship manager/sales person of the
above distributor/sub broker or notwithstanding the advice of in-appropriateness, if any, provided by the employee/relationship manager/sales person of the distributor/sub broker”.
Upfront commission shall be paid directly by the investor to the AMFI registered Distributors based on the investors’ assessment of various factors including the service rendered
by the distributor. For Direct investments, please mention ‘Direct’ in the column ‘Distributor Code’.
^I/We, have invested in the below mentioned scheme of Samco Mutual Fund under the Direct Plan. I/We hereby give my/our consent to share/provide the transaction data feed /
portfolio holdings / NAV etc. in respect of this particular transaction, to the SEBI Registered Investment Advisor (RIA) bearing the above mentioned registration number.

SIGNATURE (s)

SOLE / FIRST APPLICANT SECOND APPLICANT THIRD APPLICANT

MODE OF HOLDING (In case of Demat Purchase Mode of Holding should be same as in Demat Account) Single Joint Anyone or Survivor (Default)

1. APPLICANT INFORMATION (Mandatory) to be filled in block letters (Refer Instruction No.II)

Folio No. (For Existing unit holders)

NAME OF SOLE /1ST APPLICANT Mr. / Ms. / M/s.
PAN CKYC No. Date of Birth DD/MM/YYYY
Mailing address

City State Pin code

Mobile No. Email ID
I/We hereby declare that the email address and the mobile number provided on the application form belongs to (Please tick  ) any one from the below options) -
Self Spouse My dependents My Childrens
Please note: In the event that the mobile number or the email id provided herein above does not appear to be that of the unit holder’s, then the AMC shall send suitable
communication in this regard to the unit holder.
(Legal Entity Identifier Number is Mandatory for Redemption. Transaction value of
LEI Code Valid upto DD/MM/YYYY INR 50 crore and above for Non-Individual investors. Refer instruction no. XXII)

GUARDIAN DETAILS (In case First / Sole Applicant is minor) / CONTACT PERSON - DESIGNATION / POA HOLDER (In case of Non-Individual Investors)
Mr. / Ms.
Relationship with Minor/Designation PAN CKYC No.

SECOND APPLICANT

Mr. / Ms.
PAN CKYC No.

THIRD APPLICANT

Mr. / Ms.
PAN CKYC No.

UNIT HOLDING OPTION Physical Mode Demat Mode (Mandatory to provide the demat details in case mode of holding tick as demat mode)

DP ID NO.: Depository Participant Name:

CDSL/NSDL Please Note: Demat Account Details of First / Sole Applicant (Name should be as per demat account)
Beneficiary A/C No. (Please Note: Please attach copy of Client Master List.)

TAX STATUS (Applicable for First / Sole Applicant)

Resident Individual FIIs NRI - NRO HUF Club / Society PIO Body Corporate Minor Government Body
Trust NRI - NRE Bank & FI Sole Proprietor Partnership Firm QFI Provident Fund Others

MANDATORY PROOF OF DATE OF BIRTH FOR MINORS (Any One) & Relationship Proof
Birth Certificate Marksheet (Hsc/Icse/Cbse) School Leaving Certificate Passport Others

ACKNOWLEDGEMENT SLIP
Application No.
MUT U AL F U N D To be filled in by the investor

Received from: Mr. / Ms. / M/s an application for

units of Samco Flexi Cap Fund Plan: Regular Direct Option: Growth Collection Center’s Stamp &
Receipt Date and Time
vide Cheque No Dated Amount (R)

Drawn on Bank
Branch
Please note: All purchases are subject to realization of cheques and as per applicable load structure (please refer Scheme Information Document)
 OVERSEAS APPLICANT DETAILS
ADDRESS (Mandatory for NRI/FII applicant*)

Country Zip Code For NRI applicants Indian Overseas

E-MAIL COMMUNICATION (Please )

Default communication mode is through ‘email’. If email address is not provided then please ‘Opt-in’ to receive below documents in physical copy by ticking the option
below: Annual Report Abridged Annual Report Other Statutory Information

2. KYC DETAILS (Mandatory - Refer Instruction No XI for details)

OCCUPATION (Please tick )
First Applicant: Business Service Professional Agriculturist Housewife Student Defence
Bureaucrat Forex Dealer Unlisted Company Body Corporate Listed Company Others
Second Applicant: Business Service Professional Agriculturist Housewife Student Defence
Bureaucrat Forex Dealer Unlisted Company Body Corporate Listed Company Others
Third Applicant: Business Service Professional Agriculturist Housewife Student Defence
Bureaucrat Forex Dealer Unlisted Company Body Corporate Listed Company Others

GROSS ANNUAL INCOME (Please tick )

First Applicant: Below 1 Lac 1-5 Lacs 5-10 Lacs 10-25 Lac > 25 Lacs - 1 Crore > 1 Crore
OR Net worth (Mandatory for Non - Individuals) R as on DD/MM/YYYY (Not older than 1 year)
Second Applicant: Below 1 Lac 1-5 Lacs 5-10 Lacs 10-25 Lac > 25 Lacs - 1 Crore > 1 Crore
OR Net worth (Mandatory for Non - Individuals) R as on DD/MM/YYYY (Not older than 1 year)
Third Applicant: Below 1 Lac 1-5 Lacs 5-10 Lacs 10-25 Lac > 25 Lacs - 1 Crore > 1 Crore
OR Net worth (Mandatory for Non - Individuals) R as on DD/MM/YYYY (Not older than 1 year)

For Individuals (Please tick )

First Applicant Second Applicant Third Applicant
I am Politically Exposed Person
I am Related to Politically Exposed
Not Applicable
For Non-Individual Investors (Companies, Trust, Partnership etc.)
Is the company a Listed Company or Subsidiary of Listed Company or Controlled by a Listed Company : Yes No (If No, please attach mandatory UBO Declaration)
Foreign Exchange / Money Charger Services Yes No Gaming / Gambling / Lottery / Casino Services Yes No
Money Lending / Pawning Yes No

3. FATCA/CRS DETAILS - Non Individual Investors should mandatory fill separate FATCA/CRS details form (Refer Instruction No.XVIII)

Sole / First Applicant / Guardian 2nd Applicant 3rd Applicant POA

Place & Country
of Birth
Country # Tax Payer Ref Identification Country # Tax Payer Ref Identification Country # Tax Payer Ref Identification
ID No Type (TIN or other, ID No Type (TIN or other, ID No Type (TIN or other,
please specify) please specify) please specify)

#Please indicate all countries, other than India, in which you are a resident for tax purpose, associated Taxpayer Identification Number & it’s Identification type e.g: TIN etc.

4. POWER OF ATTORNEY (POA) - If investment is being made by a Constitutional Attorney, please submit notarised copy of POA
POA NAME Mr. / Ms. / M/s. PAN

5. NOMINATION DETAILS (Please tick )

I / We hereby confirm that I / We do not wish to exercise the right of nomination in respect of units subscribed / purchased by me / us.
OR
I/We wish to register my/our Nominee as per below details: (Mandatory for new Folios of Individuals where mode of holding is single)
Name of Nominee Date of Birth Allocation Name of Legal Guardian/Parent Relationship with
(If Nominee is minor) (%) (If Nominee is minor) Nominee

CHECKLIST: Please submit the following documents with your application (where applicable). All documents should be original/true copies certified by a Director/Trustee /Company Secretary /Authorised signatory / Notary Public)
Documents Individual Companies Societies Partnership Firms Investment through POA Trusts NRI FIIs PIO
Resolution/ Authorisation to invest     
List of authorised signatories with specimen signatures      
Trust Deed 
Bye-laws 
Partnership Deed 
Overseas Auditor Certificate 
Notarised POA 
Proof of Address 
Copy of PAN Card / PEKRN         
KYC Acknowledgement         
PIO Card 
Foreign Inward Remittance Certificate   
6. LUMPSUM/NEW SIP-INVESTMENT DETAILS* Choice of Scheme/Plan/Option For SIP Investment Auto-Debit Form is mandatory (Refer Instruction No.VI)

Scheme Samco Flexi Cap Fund Plan: Regular Direct Option: Growth

7. BANK ACCOUNT DETAILS (Refer Instruction No.IV)

Account No. Account Type (Please ): SB Current NRO NRE FCNR
Bank Name
Bank Address
City Pin IFSC CODE MICR CODE

8. PAYMENT DETAILS
Mode of Payment (Please ): RTGS/NEFT/Fund Transfer Demand Draft Cheque One time Mandate
Cheque No. Date Gross Amount r
Net Amount r DD Charges r
Bank Details: Same as above (Please tick () if yes) Different from above (Please tick () if it is different from above and fill in the details below)
Bank/Branch & City

Account No. Account Type (Please ): SB Current NRO NRE FCNR

9. SYSTEMATIC TRANSACTION REGISTRATION DETAILS

Systematic Investment Plan (SIP) (For SIP investment it is mandate to submit SIP Mandate Registration Form)
Scheme Samco Flexi Cap Fund Plan: Regular Direct Option: Growth

Installment amount (in figures): r Installment amount (in words):

SIP Frequency: (Please ): Monthly Quarterly Half Yearly Debit Date:

SIP Period: From Date To Date Or No. of Installments: Or Perpetual:

Systematic Withdrawal Plan (SWP)

Scheme Samco Flexi Cap Fund Plan: Regular Direct Option: Growth

Amount (in figures): r Amount (in words):

SWP Frequency: (Please ): Monthly Quarterly Half yearly Yearly Option Debit Date: 1 5 10 15 25

SWP Period: From Month To Month

10. DECLARATION AND SIGNATURE(S)

Having read and understood the contents of the Scheme Information Document and Statement of Additional Information and subsequent amendments thereto including the section on
who cannot invest, “Prevention of Money Laundering” and “Know Your Customer”, I/We hereby apply to Samco Mutual fund for units of the Scheme as indicated above and agree to abide
by the terms and conditions, rules and regulations of the Scheme. I/We further declare, I am / we are authorised to invest the amount & that the amount invested by me/us in the above
mentioned Scheme(s) is derived through legitimate sources and is not held or designed for the purpose of contravention of any acts, rules, regulations or any statute or legislation or
any other applicable laws or notifications, directions issued by the governmental or statutory authority from time to time. It is expressly understood that I/We have the express authority
from our constitutional documents to invest in the units of the Scheme(s) and the AMC/Trustee/Fund would not be responsible if the investment is ultra vires thereto and the investment
is contrary to the relevant constitutional documents.
I/We undertake that these investments are my/our own and acknowledge that AMC reserves the right to call for such other additional information/documents as required to comply with
PMLA/KYC/FATCA norms. I/We hereby, further agree that the Fund can directly credit all the redemption amount to my bank details given above. I/We hereby declare that the particulars
stated above are correct.
The ARN holder has disclosed to me/us all the commissions (in the form of trail commission or any other mode), payable to him for the different competing Schemes of various Mutual
Funds from amongst which the Scheme is being recommended to me/us. I/We further agree that the Fund/AMC can send us all types of SMS relating to the products offered by them.
Applicable to investors who have not opted for nomination facility. I/We hereby confirm that it is my/our informed decision not to avail the nomination facility offered by Samco Mutual Fund.
Applicable to NRI only: I/We confirm that I am / we are Non Resident of Indian Nationality/Origin and I/We hereby confirm that the funds for subscription have been remitted from abroad
through approved banking channels from funds in my/our Non-Resident External/Ordinary Account/FCNR Account. Please (ü) (Including amount of Additional Purchase Transaction made
in future)
Repatriation Non Repatriation

Date :
SIGNATURE (s)
Place : SOLE / FIRST APPLICANT SECOND APPLICANT THIRD APPLICANT
Systematic Investment Plan (SIP)
Mandate Registration Form MUT U AL F U N D

Sponsor: Samco Securities Limited Samco Mutual Fund

Trustee Company: Samco Trustee Private Limited 1003 – A, Naman Midtown, Senapati Bapat Marg, Application No. S
Investment Manager: Samco Asset Management Private Limited Prabhadevi (W), Mumbai - 400 013.

1. DISTRIBUTOR INFORMATION
Distributor Code Sub-Broker Code Internal sub broker code EUIN RIA CODE^
Employee Unique
ARN - ARN - INTERNAL CODE
IDENTIFICATION NO.
*Investors should mention the EUIN of the person who has advised the investor. If left blank, the fund will assume following declaration by the investor “I/We hereby confirm that
the EUIN box has been intentionally left blank by me/us as this transaction is executed without any interaction or advice by the employee/relationship manager/sales person of the
above distributor/sub broker or notwithstanding the advice of in-appropriateness, if any, provided by the employee/relationship manager/sales person of the distributor/sub broker”.
Upfront commission shall be paid directly by the investor to the AMFI registered Distributors based on the investors’ assessment of various factors including the service rendered by
the distributor. For Direct investments, please mention ‘Direct’ in the column ‘Name & Distributor Code’

SIGNATURE (s) SOLE / FIRST APPLICANT SECOND APPLICANT THIRD APPLICANT

2. UNITHOLDER INFORMATION
Name of Sole /1st Applicant Mr. / Ms. / M/s.
Folio No. (For Existing Unit Holders) PAN CKYC No.

3. INVESTMENT DETAILS (Choice of Plan [Please ])

Scheme Samco Flexi Cap Fund Plan: Regular Direct Option: Growth
Enrolment Period: From Date To Date OR Perpetual (Default) OR No. of Installments
First SIP Instalment via: Cheque No. Drawn on Bank and Branch
Amount: r A/c. No. Each SIP Amount: r Amount in Words
SIP Frequency: (Please )
Monthly (SIP) Quaterly (SIP) Half Yearly (SIP)
Date: D D M M Y Y Y Y Preferred Debit Date (Any day from 1st to 28th of the month) Date: D D M M Y Y Y Y Date: D D M M Y Y Y Y
I/We hereby authorize Samco Mutual Fund and their authorized service providers to debit my/our following bank account by NACH clearing for collection of SIP payments.
Note: Please allow 1 month for NACH Mandate to register and start.
SIP Step UP FACILITY:
Fixed Amount Variable (in Percentage)
Amount (Minimum 500/- Percentage (Minimum 10%
in multiple of Re 1/-) and in multiple of 5%)
Freeze # Amount OR Month-Year MM YY Freeze # Amount OR Month-Year MM YY
Frequency $ Half Yearly Yearly Frequency $ Half Yearly Yearly
$ In case of Quarterly SIP, only the Yearly frequency is available under SIP TOP UP. # Freeze the SIP Top-Up amount once it reaches a fixed predefined amount or maximum amount as mentioned in OTM.

4. Unit holding option Physical Mode (Default) Demat Mode (Demat Account details are mandatory if the investor wishes to hold the units in Demat Mode)
NSDL DP Name DP ID IN Beneficiary Account No.
CDSL DP Name Beneficiary Account No.

5. DECLARATION & SIGNATURE(S)

I/We declare that the particulars furnished here are correct. I/We authorize Samco Mutual Fund acting through its service providers to debit my/our bank account towards payment of SIP installments
and/or any lumpsum payments through an Electronic Debit arrangement/NACH (National Automated Clearing House) as per my request from time to time. If the transaction is delayed or not effected at
all for reasons of incomplete or incorrect information, I/we would not hold the user institution responsible. I/We will also inform Samco Mutual Fund about any changes in my bank account.
This is to inform you that I/We have registered for making payment towards my investments in Samco Mutual Fund by debit to my/our account directly or through NACH. I/We hereby authorize to honour
such payments and have signed and endorsed the Mandate Form. Further, I authorize my representative (the bearer of this request) to get the above Mandate verified. Mandate verification charges, if
any, may be charged to my/our account.
I also hereby agree to read the respective SID and SAI of the mutual fund before investing in any scheme of Samco Mutual Fund using this facility.

Date :
SIGNATURE (s)
Place : SOLE / FIRST APPLICANT SECOND APPLICANT THIRD APPLICANT

MUT U AL F U N D

SAMCO MUTUAL FUND