Request for Transmission of Securities by Nominee or Legal Heir Annexure C –

(For Transmission of securities on death of the Sole holder) ISR 5

To:
The Listed Issuer/RTA,
ICICI Bank Limited
ICICI BANK TOWER NEAR CHAKLI CIRCLE OLDPADRA ROAD VADODARA, GUJARAT 390007
(Address)

ICICI Bank Limited (Name of the Listed Issuer/RTA)

Name of the
Claimant(s)
Mr. SUSHIL JAIN
Name of the Guardian in case the claimant is a minor → Date of Birth of the minor*
Mr./Ms.
Relationship with Minor: Father Mother Court Appointed Guardian*
[Multiple PAN may be entered] PAN (Claimant(s)/Guardian): |A|J|T|P|J|6|6|1|1|Q KYC
Acknowledgment attached KYC form attached
Tax Status: Resident Individual Resident Minor (through Guardian) NRI PIO Others
(please specify)
*Please attach relevant proof
I/We, the claimant(s) named hereinabove, hereby inform you about the demise of the below
mentioned Securities Holder(s) and request you to transmit the securities held by the
deceased holder(s) in my/our favour in my/our capacity as –
Nominee Legal Heir Successor to the Estate of the deceased Administrator of
the Estate of the deceased
Name of the deceased holder(s) Date of
demise**
1) OMPRAKASH JAIN 27 / 02 / 2018
2) DD / MM / YYYY
3) DD / MM / YYYY
**Please attach certified copy of Death Certificate.
Securities(s) & Folio(s) in respect of which Transmission of securities is being
requested
No. of % of
Name of the Company Folio No. Securities Claim@
1) ICICI Bank Limited 1092734 250 100%
2) ICICI Bank Limited 1092734 25 100%
3)
4)
@As per Nomination OR as per the Will/Probate/Succession Certificate/Letter of
Administration/ Legal Heirship Certificate (or its equivalent certificate)/ Court Decree,
if applicable.

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Contact details of the Claimant (s) [Provision for multiple entries may be made]
Mobile No.+91|9 |4|2|5|4|1|0|5|0|1| Tel. No. STD -
Email Address-: [email protected]
Address (Please note that address will be updated as per address on KYC form /
KYC Registration Agency records)

Address Line 1 9/2 Marothiya Bazar

Address Line 2 Bajaj khana chowk
City: Indore State: Madhya Pradesh
PIN: 4|5|2|0|0|2|
Bank Account Details of the Claimant
Bank Name: Punjab National Bank
Account No. 0212000100141435 11-digit IFSC: PUNB0021200

A/c. Type (✓) SB Current NRO NRE FCNR 9-digit MICR No.: 452024002

Name of bank branch : Sitlamata Bazar, Indore

City: Indore (M.P.)
PIN: 452002
Please attach & tick✓ Cancelled cheque with claimant’s name printed OR Claimant’s
Bank Statement/Passbook (duly attested by the Bank Manager)
I also request you to pay the UNCLAIMED amounts, if any, in respect of the deceased
securities holder(s) by direct credit to the bank account mentioned above.

Additional KYC information (Please tick✓ whichever is applicable)

Occupation Private Sector Service Public Sector Service Government Service
Business Professional
Agriculturist Retired Home Maker Student Forex Dealer Others
(Please specify)
The Claimant is a Politically Exposed Person Related to a Politically Exposed
Person Neither (Not applicable)
Gross Annual Income (₹) Below 1 Lac 1-5 Lacs 5-10 Lacs 10-25 Lacs
25 Lacs-1crore >1 crore
FATCA and CRS information
Country of Birth : India Place of Birth: Indore
Nationality: Indian
Are you a tax resident of any country other than India? Yes No
If Yes, please mention all the countries in which you are resident for tax purposes and the
associated Taxpayer Identification Number and its identification type in the column below
Country Tax-Payer Identification Number Identification Type

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 Nomination@ (Please ✓ one of the options below)
I/We DO NOT wish to make a nomination. (Please tick ✓ if you do not wish to
nominate anyone)

I/We wish to make a nomination and hereby nominate the person/s more particularly
described in the attached Nomination Form to receive the securities held in my/our
folio in the event of my / our death.
@ Guardian of a minor is not allowed to make a nomination on behalf of the minor

Declaration and Signature of the Claimant(s)

I/We have attached herewith all the relevant / required documents as indicated in the
attached Ready Reckoner as per Annexure A.
I/We confirm that the information provided above is true and correct to the best of my
knowledge and belief.
I/We undertake to keep ICICI Bank Limited (Name of the Company) / its RTA informed about
any changes/modification to the above information in future and also undertake to provide any
other additional information as may be required by the RTAs.
I/We hereby authorize ICICI Bank Limited (Name of the Company) and its RTA to provide/
share any of the information provided by me/us including my holdings in the (Name of the
Company) to any governmental or statutory or judicial authorities/agencies as required by law
without any obligation of informing me/us of the same.
Place: Indore
Date:
Signature of Claimant(S)

Documents Attached
Copy of Death Certificate of the deceased holder
 Copy of Birth Certificate (in case the Claimant is a minor)
Copy of PAN Card of Claimant / Guardian
KYC Acknowledgment OR
 KYC form of Claimant
Cancelled cheque with claimant’s name printed OR Claimant’s Bank
Statement/Passbook
Nomination Form duly completed
Annexure D - Individual Affidavits given EACH Legal Heir
Original security certificate(s)
Annexure E - Bond of Indemnity furnished by Legal Heirs
 Annexure F - NOC from other Legal Heirs

*Note: For transmission service requests, Form ISR-4 as per SEBI circular
SEBI/HO/MIRSD/MIRSD_RTAMB/P/CIR/2022/8 dated January 25, 2022 will not be required.

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