COMMON TRANSACTION FORM INCLUDING OTM FACILITY (For existing Unitholders only)

BROKER CODE (ARN CODE)/ SUB-BROKER ARN CODE Employee Unique SUB-BROKER CODE
RIA CODE# Identification No. (EUIN) (As allotted by ARN holder)
#By mentioning RIA code, I/we authorize you to share with the Investment Adviser the details of my/our transactions in the scheme(s) of ICICI Prudential Mutual Fund.
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.
Declaration for "execution-only" transaction (only where EUIN box is left blank)
I/We hereby confirm that the EUIN box has been intentionally left blank by me/us as this is an “execution-only” transaction without any interaction or advice by the
employee/relationship manager/sales person of the above distributor or notwithstanding the advice of in-appropriateness, if any, provided by the employee/relationship
manager/sales person of the distributor and the distributor has not charged any advisory fees on this transaction.

Signature of Sole/First Holder Signature of Second Holder Signature of Third Holder

FOLIO NO. (Mandatory): TAX STATUS: MODE OF HOLDING:
1st Holder
)
(Mandatory)
tho lder(s tatus
*
2nd Holder
e o f Uni PAN* KYC S
3rd Holder Nam
* PAN & KYC are mandatory for all applicants including NRIs. Date of Birth (1st Holder) (Mandatory for ICICI Prudential
Retirement Fund) - (Refer Instruction No. I on page 2) D D M M Y Y Y Y

Additional Purchase Request (Cheque/DD to be drawn in favour of “Name of the Scheme”). In case you do not mention Plan and/or Option units will
be allotted under default option as per respective scheme information documents.
Scheme Name PLAN: OPTION:

Payment Mode (Please tick any one only): OTM (One Time Bank Mandate) Cheque DD Fund Transfer RTGS / NEFT
Cheque/DD/Instrument No. __________________________ Payment Date/Instrument Date: ____ / ____ / ______ Amount (Rs.) : ________________________
Bank Name**: _____________________________________________________ Branch: _____________________________ City: ____________________________
Bank Account Savings Current NRO NRE FCNR
** Please refer to
A/c No.** instruction no.2 Type
Others ___________________________ (Please specify)

I/We hereby confirm having initiated the Transfer / RTGS for transfer of INR ___________________________________ from our account no. ____________________________________ with

_________________________________________ (Bank) to your account no.______________________________________ with __________________________________________________ (Bank).

Documents attached to avoid Third Party Payment Rejection where applicable: In case, the additional purchase amount is `10,000 or above and distributor has opted to receive transaction charges, `100/-
Bank Certificate - for DD Third Party Declaration will be deducted from the Purchase amount and paid to the distributor. Units shall be allotted for the balance amount only.
For third party investment/pre-funded instrument, please fill in a separate declaration form as available with AMC.
Switch Request (Please refer to the SID of the scheme you are switching from and to) I wish to switch: Rs. or Units
From To
(Scheme) Plan: (Scheme) Plan:

(Option) (Option)

Have you invested long enough ? Redemption Request

• Longer investment time period may allow your money the Benefit of
BEFORE YOU

Please
Compounding. Rs. or Units
REDEEM

Redeem
• We recommend you check your investment horizon against your financial
Scheme
goals and not to get swayed by short term market movements.
• Have you been invested long enough to avoid any short term capital gain Plan
tax and exit load charges ?
Option
Consult your financial advisor for the appropriate investment horizon!
If you have registered for multiple bank account facility in the above folio please specify the bank details in which you wish to receive the redemption proceeds. The bank account should be one of the registered
bank account in the folio else the payout will be released to the default bank account registered for the folio.
Bank Name Bank A/c No.

Contact details of First/Sole applicant

Mobile Number and/or Land Line Number

E-mail Address

As per the press release dated April 11, 2017 issued by Ministry of Finance, the AMC has blocked/freezed the folios opened between 1st July 2014 to 31st August 2015 where FATCA self certification is not
provided. The AMC shall not process any transaction which is initiated by the Investor in such folio(s) unless FATCA self-certification is provided by the Investor and due diligence is completed by the AMC.
YOUR CONFIRMATION/DECLARATION: I/We have read and understood the contents of the Scheme Information Document(s)/Key Infromation Memorandum(s) & Statement of Additional
Information(s) of the Scheme(s) and agree to abide by the terms, conditions, rules and regulations of the Scheme(s) as on the date of this transaction. 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 hereby confirm that I/we have not been offered/communicated any indicative portfolio and/or any indicative yield for this investment. I/we declare that the email address provided in the form
belongs to me/us or to spouse, dependent children or dependent parents (applicable to individual investors only).

Signature(s)
First Holder Second Holder Third Holder

(Please See Overleaf)

Folio No. ............................................................................................................. Purchase Redeem Switch Date: .................................................

Scheme ....................................................................................................................................................................... Amount Rs. ............................................................... or Units .......................................

From Scheme (in case of switch) ........................................................................................................... To Scheme .........................................................................................................................................

COMMON TRANSACTION FORM INCLUDING OTM FACILITY (Contd.)

INSTRUCTIONS:

I. DATE OF BIRTH (DOB)

a) Date of birth of the First Unit Holder is mandatory for subscribing to the units of the Scheme, alongwith a copy of proof of date of birth as detailed in point (d) evidencing date of birth of the First Unit holder.
b) AMC reserves the right to process the application where only date of birth is provided in the application form or the date of birth is retrievable from other sources.
c) Age shall be computed with reference to years completed on the date of allotment.
d) Acceptable Documents for Proof of date of Birth: Self attested copy of PAN, Passport, Driving licence or any other documents issued by Government departments of foreign jurisdictions and letter issued by
Foreign Embassy or Mission in India; Identity card with applicants name and date of birth issued by any of the following: Central/ State Government Departments, Statutory/Regulatory Authorities, Public Sector
Undertakings, Scheduled Commercial Banks, Public Financial Institutions, Colleges affiliated to Universities, Professional Bodies such as ICAI, ICWAI, ICSI, Bar Council, etc., to their Members. AMC reserves
right to reject or process the application or ask for additional documentation subject to internal verification.

II. ADDITIONAL PURCHASE THROUGH OTM FACILITY:

1) Investor can invest through OTM facility registered in the folio and does not have to provide any cheque or transfer details.
2) Bank details need to be provided if transaction is through OTM mode, if no bank details are mentioned or no OTM mandate is registered for the given bank details then default bank mandate under OTM facility
will be considered to debit the purchase amount
3) For any transaction above Rs. 2 lacs and/or transactions in Liquid and Money Market schemes or plans, units will be allotted based on funds realization (applicable NAV). The AMC would not be liable for any
delay in crediting the scheme collection accounts by the Service Providers which may result in a delay in application of NAV.
4) Purchase transaction or any other subsequent transaction may be liable for rejection at banker's end, if the frequency for the registered OTM is other than "As and when presented" and/ or if the purchase
amount is other than fixed amount or more than maximum amount registered in the mandate.
5) AMC reserves right to reject or process the application subject to internal verification.

In case there is any change in your KYC information please update the same by using the prescribed ‘KYC Change Request Form’, available on our website
www.iciciprumf.com under the downloads section, and submit the same at the Point of Service of any KYC Registration Agency.