Distributor/RIA name and ARN/Code
Sub Broker ARN & Name
For Office use only
EUIN (Refer note below)
I am a First Time Investor in Mutual Fund Industry.
I am an Existing Investor in Mutual Fund Industry.
I/We confirm that the EUIN box is intentionally left blank by me/us as this is an “execution-only”
transaction without any interaction or advice by the distributor personnel concerned.
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.
Sub Broker/Branch/RM Internal Code
Sole / First Applicant's Signature Mandatory
1. FIRST APPLICANT’S DETAILS
Name of First Applicant (Should match with PAN/Aadhar Card)
Mode of Holding (Please tick )
Joint (Default) Anyone or Survivor
Status of Sole/1st Applicant (Please tick )
Indian Resident Individual Minor (Resident) Minor (Repatriable) Minor (Non Repatriable)
Name of Guardian (if minor)/POA/Contact Person
City
State
Email ID
(in capital)
Occupation Details (Please tick )
Private Sector Service
Business
Public Sector Service
Government Service
Gross Annual Income (Please tick )
Below 1 Lac 1-5 Lacs 5-10 Lacs 10-25 Lacs >25 Lacs-1 crore >1 crore
Net-worth in
(Mandatory for Non-Individuals)
(Not older than 1 year)
For Individuals (Please tick )
Not Applicable I am Politically Exposed Person I am Related to Politically Exposed Person
3a.
3b.
3c.
Mobile
+91
Tel
(STD Code)
Address
3d.
2nd Applicant
Landmark
Pin Code
(Mandatory)
as on
D D M M Y Y Y Y
`
Others (Please tick )
Not Applicable Politically Exposed Person (PEP) Related to a Politically Exposed Person (PEP)
Occupation Details (Please tick )
Private Sector Service
Business
Public Sector Service Government Service
Professional
Agriculturist
Retired Housewife Student
Forex Dealer Others
(Please specify)
a.
b.
c.
Others (Please tick )
b.
c.
APPLICATION FORM
Application No.:
Please read Product labeling details
available on cover page and instructions before filling this Form
ACKNOWLEDGEMENT SLIP (To be filled in by the investor)
Application No.
DSP MUTUAL FUND
From
Received, subject to realisation and verification an application for purchase of Units as mentionedin the application form.
Cheque no.
Amount
Scheme
DSP
a. Residential & Business
b. Residential
c. Business
d. Registered Office
Address Type (Mandatory)
Not Applicable Politically Exposed Person (PEP) Related to a Politically Exposed Person (PEP)
Gross Annual Income (Please tick )
Below 1 Lac 1-5 Lacs 5-10 Lacs 10-25 Lacs >25 Lacs-1 crore
Gross Annual Income (Please tick )
Below 1 Lac 1-5 Lacs 5-10 Lacs 10-25 Lacs >25 Lacs-1 crore
>1 crore
>1 crore
NRI (Repatriable) NRI (Non-Repatriable) PIO Sole Proprietorship HUF - Indian HUF - NR Partnership Firm Limited Partnership (LLP) Public Ltd. Co. Private Ltd. Co.
Body Corporate Bank FIs Insurance Companies Government Body AOP/BOI Trust Society Provident Fund Superannuation/Pension Fund Gratuity Fund Mutual Fund
FII FPI-Category I/II/III FCRA GDN Defence Establishment NPS Trust Others _____________________________________________________________ (Please specify)
Are you a Non-Profit Organization [NPO] or Company u/s 25 (Companies Act 1956) or u/s 8 of Companies, Act, 2013: Yes No
Professional
Agriculturist
Retired Housewife Student
Forex Dealer Others
(Please specify)
2. CONTACT DETAILS AND CORRESPONDENCE ADDRESS (As per KYC records)
3. KYC DETAILS (Mandatory)
4. JOINT APPLICANTS (IF ANY) DETAILS
PAN
CKYC - KIN
PAN
CKYC - KIN
Occupation Details (Please tick )
Private Sector Service
Business
Public Sector Service Government Service
Professional
Agriculturist
Retired Housewife Student
Forex Dealer Others
(Please specify)
a.
(Should match with PAN/Aadhar Card)
3rd Applicant
(Should match with PAN/Aadhar Card)
PAN
(1st Appl / Guardian)
D D
Y Y Y Y
D D
M M
Y Y Y Y
Date of Birth
D D
M M
Y Y Y Y
Date of Birth
(1st Appl / Minor) (attach proof)
D D
M M
Y Y Y Y
Date of Birth
Guardian is:
Father Mother
Court Appointed
PAN of POA
KYC attached
Existing Folio
D D
M M
Y Y Y Y
Date of Birth (Guardian)
CKYC - KIN
QFUND.IN
Bank A/C No.
IFSC code: (11 digit)
MICR code (9 digit)
(This is a 9 digit number next to your cheque number)
City
Pin
A/C Type
Savings Current NRE NRO FCNR Others
# Please indicate all Countries, other than India, in which you are a resident for tax purpose, associated Taxpayer Identification Number and it's Identification type eg. TIN etc.
*If TIN is not available or mentioned, please mention reason as: 'A' if the country does not issue TINs to its residents; 'B' & mention why you are unable to obtain a TIN; 'C' if the authorities of the country
of tax residence entered above do not require the TIN to be disclosed.
1
2
3
Identification
Type/Reason*
Tax Identification
Number
Country #
Tax Identification
Number
Country #
Tax Identification
Number
Country #
1
2
3
1
2
3
Identification
Type/Reason*
Identification
Type/Reason*
Sole/First Applicant/Guardian
2nd Applicant
Place & Country of Birth
For Individuals (Mandatory)
Non Individual investors including HUF should mandatorily fill separate FATCA/CRS details form
3rd Applicant
POA
PLACE
COUNTRY
COUNTRY
COUNTRY
Place & Country of Birth Place & Country of Birth
PLACE
PLACE
Nationality
Indian U.S. Other
Nationality
Indian U.S. Other
Nationality
Indian U.S. Other
Second Applicant Third Applicant Sole / First Applicant / Guardian POA holder, if any
Individuals (single or joint applicants) are advised to avail Nomination facility.
Nominee 1
Nominee 2
Nominee 3
Attach OTM form, if not already registered.
Mention LUMPSUM and First SIP
Cheque Details below
One time Lumpsum Investment
SIP: Systematic Investment Plan.
Cheque/DD should be in favour of: “DSP Mutual Fund” if single cheque with multiple schemes OR “Scheme Name”, in case of single scheme / scheme wise cheques.
Full Scheme/Plan/Option/Sub Option
A/c. Type
Savings Current NRE NRO FCNR Others
Payment from Bank A/c No.
Pay In A/c No.
Bank Name
Documents Attached to avoid Third Party Payment Rejection, where applicable: Bank Certificate, for DD Third Party Declarations
1. DSP -
Scheme
Plan
Option/Sub Option
Total
Amount (`)
2. DSP -
Scheme
Plan
Option/Sub Option
3. DSP -
Scheme
Plan
Option/Sub Option
Payment Mode: Cheque DD
RTGS NEFT Funds transfer
DD charges, if any
Cheque/DD/RTGS/NEFT Details:
Amount in words
I/We wish to nominate. I/We DO NOT wish to nominate and sign here 1st Applicant Signature (Mandatory)
Nominee/ Guardian
Signature
Amount in Figures
Ref. No.
D D
M M
Y Y Y Y
Date
Quick
Checklist
Name, Address are correctly mentioned
Email ID / Mobile number are mentioned
KYC information provided for each applicant
FATCA/CRS details provided for each applicant
Full scheme name, plan, option is mentioned
Pay-In bank details and supportings are attached
Nomination facility opted
Form is signed by all applicants
Additional documents provided if investor name is
not pre-printed on payment cheque or if
Demand Draft is used.
Non Individual investors should attach
FATCA Details and Declaration Form
UBO Declaration Form
Email: service@dspim.com
Contact Centre: 1800 200 4499
Website: www.dspim.com
Nominee Name
Allocation %
Guardian Name
(In case of Minor)
Total = 100% Address
5. FATCA and CRS DETAILS
6. BANK ACCOUNT DETAILS
Bank Name
(Avail Multiple Bank Registration Facility)
7. INVESTMENT ANDPAYMENTDETAILS
(Defaultplan/option/sub option will be applied incase of no information, ambiguity or discrepancy)
8. NOMINATION DETAILS
In Demat mode:
Enclose for demat option:
Client Master List
Transaction/Holding Statement
DIS Copy
Depository Participant (DP) ID (NSDL only)
Beneficiary Account Number (NSDL only)
In Account Statement
Mode (default):
NSDL:
I N
CDSL:
9. UNIT HOLDING OPTION:
Having read and understood the contents of the Scheme Information Document and Statement of Additional Information, Key Information Memorandum, Instructions and addenda issued by DSP Mutual Fund form
time to time, I / We, hereby apply to the Trustee of DSP Mutual Fund for Units of the relevant Scheme/Plan/Option and agree to abide by the terms and conditions, rules and regulations. I / We have understood the
information requirements of the application form, including FATCA and CRS requirements, terms and conditions (read along with instructions and scheme related documents) and hereby accept the same and
further confirm that the information provided by me/us on this form is true, correct, and complete. I / We declare that the amount invested in the Scheme is through legitimate sources only and is not designed for
the purpose of contravention or evasion of any Act, Regulation, Rule, Notification, Directions or any other applicable laws enacted by the Government of India or any Statutory Authority.
11. DECLARATION & SIGNATURES
Relationship with
applicant
I/We wish to receive physical copy of the annual report/abridged summary, if email id is not registered in the folio.
10.
I/We acknowledge and confi rm that the information provided above is/are true and correct to the
best of my/our knowledge and belief and provided after necessary consultation with tax professionals.
I / We have understood the information requirements of the application form, including FATCA and CRS
requirements, terms and conditions (read along with instructions and scheme related documents) and
hereby confi rm that the information provided by me/us on this form are true, correct, and complete.
Place :
Page 1 of 2
Date :
Authorized Signatories [with Company/Trust/Firm/Body Corporate seal]
FATCA and CRS DETAILS (Mandatory)
(Please consult your professional tax advisor for further guidance on FATCA & CRS classification)
PART I (to be fi lled by Financial Institutions or Direct Reporting NFEs)
We are a, (please tick as appropriate)
Financial Institution
(Refer defi nition A)
or
Direct reporting NFE
(Refer defi nition B)
G I I N
Note: If you do not have a GIIN but you are sponsored by another entity, please provide your sponsor's
GIIN above and indicate your sponsor's name below
Name of sponsoring entity:
G I I N - Not Available
Applied for
If the entity is a financial institution,
Not required to apply for - please specify 2 digits sub-category
(refer defi nition C)
Not obtained – Non-participating FI
PART II (please fill Any One as appropriate, to be filled by NFEs other than Direct Reporting NFEs)
Is the Entity a publicly traded company?
(that is, a company whose shares are regularly
traded on an established securities market)
(Refer defi nition D1)
Yes
(If yes, please specify any one stock exchange on which the stock is regularly traded)
Name of stock exchange_______________________________________________________________________
Is the Entity a related entity of a
publicly traded company?
(a company whose shares are regularly
traded on an established securities market)
(Refer defi nition D2)
Yes
(If yes, please specify name of the listed company and one stock exchange on which the stock is regularly traded)
Name of listed company______________________________________________________________________
Nature of relation:
Subsidiary of the Listed Company OR Controlled by a Listed Company
Name of stock exchange_______________________________________________________________________
Is the Entity an Active NFE?
(Refer defi nition D3)
Yes
Also provide UBO Form
Nature of Business____________________________________________________________________________
Please specify the sub-category of Active NFE
(Mention code - refer D3)
Is the Entity a Passive NFE?
(Refer defi nition E2)
Yes
Also provide UBO Form
Nature of Business_____________________________________________________________________________
FATCA, CRS AND ADDITIONAL KYC
Please refer Page 2 for Defi nitions / Instructions / Guidance
Mandatory for Non-Individual Investors, including HUF
Details and Declaration form
INVESTOR DETAILS
Entity Name:
Folio Nos
Type of Address given at KRA
PAN Application No.
INCORPORATION and TAX RESIDENCY DETAILS (Mandatory)
City of Incorporation: Country of Incorporation: Date of Incorporation:
Is Entity a tax resident of any country other
than India?
Yes No
(If yes, please provide country/ies in which the entity is a resident
for tax purposes and the associated Tax ID number below)
In case TIN or its functional equivalent is not available, please provide Company Identifi cation number of Global Entity Identifi cation Number or GIIN, etc.
Country of Tax Residency TIN or equivalent number Identifi cation Type/Reason*
1.
2.
3.
4.
In case the Entity's Country of Incorporation / Tax residence is U.S. but Entity is not a Specified U.S.
Person (as per defi nition E5), please mention the exemption code in the box:
(refer defi nition D4)
Gross Annual Income (Please tick ) Below 1 Lac 1-5 Lacs 5-10 Lacs 10-25 Lacs >25 Lacs-1 crore >1 crore
Net-worth in
`_____________________________ as on
DD M/ /M YY YY
(Not older than 1 year)
ADDITIONAL KYC DETAILS (Mandatory)
Residential or Business Residential Business Registered Offi ce
V2 15/NOV/2016
A. Financial Institution (FI)- The term FI means any fi nancial institution that is a:
1 Depository institution: Accepts deposits in the ordinary course of banking or similar business.
2 Custodial institution: An entity that as a substantial portion of its business, holds nancial assets for the
account of others and where the entity's gross income attributable to holding nancial assets and related
nancial services equals or exceeds 20 percent of the entity's gross income during the shorter of-
(a) The three-year period ending on December 31 of the year preceding the year in which the determination
is made;
(b) The period during which the entity has been in existence before the determination is made)
3 Investment entity : Conducts a business or operates for or on behalf of a customer for any of the following
activities: (a) Trading in money market instruments, foreign exchange, foreign currency,etc. (b) Individual
or collective portfolio management. (c) Investing, administering or managing funds, money or nancial
asset on behalf of other persons. [OR] The gross income of which is primarily attributable to investing,
reinvesting, or trading in nancial assets, if the entity is managed by another entity that is a depository
institution, a custodial institution, a specifi ed insurance company, or an investment entity described herein.
An entity is treated as primarily conducting as a business one or more of the 3 activities described above, or
an entity's gross income is primarily attributable to investing, reinvesting, or trading in fi nancial assets of the
entity's gross income attributable to the relevant activities equals or exceeds 50 percent of the entity's gross
income during the shorter of: (i) The three-year period ending on 31 March of the year preceding the year in
which the determination is made; or (ii) The period during which the entity has been in existence.
4 Specifi ed Insurance company: Entity issuing insurance products i.e. life insurance or cash value products.
5 Holding company or treasury company: Is an entity that is a holding company or treasury centre that
is a part of an expanded affi liate group that includes a depository, custodial institution, specifi ed insurance
company or investment entity
B. Direct Reporting NFE: means a Non-fi nancial Entity (NFE) that elects to report information about its direct
or indirect substantial U.S. owners to the IRS
C. GIIN not required: Categories with codes
Code Sub-Category
01 Governmental Entity, International Organization or Central Bank
02 Treaty Qualifi ed Retirement Fund; a Broad Participation Retirement Fund; a Narrow
Participation Retirement Fund; or a Pension Fund of a Governmental Entity, International
Organization or Central Bank
03 Non-public fund of the armed forces, an employees' state insurance fund, a gratuity fund or
a provident fund
04 Entity is an Indian FI solely because it is an investment entity
05 Qualifi ed credit card issuer
06 Investment Advisors and Investment Managers
07 Exempt collective investment vehicle
08 Trustee of an Indian Trust
09 FI with a local client base
10 Non-registering local banks
11 FI with only Low-Value Accounts
12 Sponsored investment entity and controlled foreign corporation
13 Sponsored, Closely Held Investment Vehicle
14 Owner Documented FI
D. Non-Financial Entity (NFE): Entity that is not a nancial institution (including a territory NFE). Types of NFEs
excluded from FATCA reporting are as below:
1. Publicly traded corporation (listed company): A company is publicly traded if its stock are regularly
traded on one or more established securities markets.
2. Related entity of a listed company: The NFE is a related entity of an entity of which is regularly traded
on an established securities market;
3. Active NFE: (is any one of the following):
Code Sub-Category
01 Less than 50 percent of the NFE’s gross income for the preceding nancial year or other appropriate
reporting period is passive income and less than 50 percent of the assets held by the NFE during
the preceding calendar year or other appropriate reporting period are assets that produce or are
held for the production of passive income;
02 The NFE is a Governmental Entity, an International Organization, a Central Bank, or an entity
wholly owned by one or more of the foregoing;
03 Substantially all of the activities of the NFE consist of holding (in whole or in part) the outstanding
stock of, or providing nancing and services to, one or more subsidiaries that engage in trades or
businesses other than the business of a Financial Institution, except that an entity shall not qualify
for NFE status if the entity functions (or holds itself out) as an investment fund, such as a private
equity fund, venture capital fund, leveraged buyout fund, or any investment vehicle whose purpose
is to acquire or fund companies and then hold interests in those companies as capital assets for
investment purposes;
04 The NFE is not yet operating a business and has no prior operating history, but is investing capital
into assets with the intent to operate a business other than that of a Financial Institution, provided
that the NFE shall not qualify for this exception after the date that is 24 months after the date of
the initial organization of the NFE;
05 The NFE was not a Financial Institution in the past ve years, and is in the process of liquidating its
assets or is reorganizing with the intent to continue or recommence operations in a business other
than that of a Financial Institution;
06 The NFE primarily engages in fi nancing and hedging transactions with, or for, Related Entities that
are not Financial Institutions, and does not provide fi nancing or hedging services to any Entity that
is not a Related Entity, provided that the group of any such Related Entities is primarily engaged in
a business other than that of a Financial Institution;
07 Any NFE is a ‘non for profi t’ organization which meets all of the following requirements:
It is established and operated in its jurisdiction of residence exclusively for religious, charitable,
scientifi c, artistic, cultural, athletic, or educational purposes; or it is established and operated
in its jurisdiction of residence and it is a professional organization, business league, chamber
of commerce, labor organization, agricultural or horticultural organization, civic league or an
organization operated exclusively for the promotion of social welfare;
It is exempt from income tax in India;
It has no shareholders or members who have a proprietary or benefi cial interest in its income
or assets;
The applicable laws of the NFE’s jurisdiction of residence or the NFE’s formation documents require that, upon
the NFE’s liquidation or dissolution, all of its assets be distributed to a governmental entity or other non-profi t
organization, or escheat to the government of the NFE’s jurisdiction of residence or any political subdivision
thereof.
4. Exemption Codes for U.S. persons:
5 Holding company or treasury company: Is an entity that is a holding company or treasury centre that is a part
of an expanded affi liate group that includes a depository, custodial institution, specifi ed insurance company
or investment entity
B. Direct Reporting NFE: means a Non-fi nancial Entity (NFE) that elects to report information about its direct or
indirect substantial U.S. owners to the IRS
C. GIIN not required categories with codes
Code Sub-Category
A An organization exempt from tax under section 501(a) or any individual retirement plan as defi ned
in section 7701(a)(37)
B The United States or any of its agencies or instrumentalities
C A state, the District of Columbia, a possession of the United States, or any of their political
subdivisions or instrumentalities
D A corporation the stock of which is regularly traded on one or more established securities markets,
as described in Reg. section 1.1472-1(c)(1)(i)
E A corporation that is a member of the same expanded affi liated group as a corporation described
in Reg. section 1.1472-1(c)(1)(i)
F A dealer in securities, commodities, or derivative fi nancial instruments (including notional principal
contracts, futures, forwards, and options) that is registered as such under the laws of the United
States or any state
G A real estate investment trust
H A regulated investment company as defi ned in section 851 or an entity registered at all times during
the tax year under the Investment Company Act of 1940
I A common trust fund as defi ned in section 584(a)
J A bank as defi ned in section 581
K A broker
L A trust exempt from tax under section 664 or described in section 4947(a)(1)
M A tax exempt trust under a section 403(b) plan or section 457(g) plan
14 Owner Documented FI
E. Other defi nitions
1 Related entity: An entity is a related entity of another entity if either entity controls the other entity or the two
entities are under common control. For this purpose, control includes direct or indirect ownership of more than
50% of the vote or value in an entity.
2 Passive NFE: The term passive NFE means any NFE that is not (i) an Active NFE (including publicly traded
entities or their related entities), or (ii) a withholding foreign partnership or withholding foreign trust pursuant
to relevant U.S. Treasury Regulations.(Note: Foreign persons having controlling interest in a passive NFE are
liable to be reported for tax information compliance purposes)
3 Passive income: The term passive income means the portion of gross income that consists of: (a) Dividends,
including substitute dividend amounts; (b) Interest; (c) Income equivalent to interest, including substitute
interest and amounts received from or with respect to a pool of insurance contracts if the amounts received
depend in whole or part upon the performance of the pool; (d) Rents and royalties, other than rents and
royalties derived in the active conduct of a trade or business conducted, at least in part, by employees of the
NFE; (e) Annuities; (f) The excess of gains over losses from the sale or exchange of property that gives rise
to passive income described in this section.; (g) The excess of gains over losses from transactions (including
futures, forwards, and similar transactions) in any commodities, but not including: (i) Any commodity hedging
transaction, determined by treating the entity as a controlled foreign corporation; or (ii) Active business gains
or losses from the sale of commodities, but only if substantially all the foreign entity’s commodities are property
(h) The excess of foreign currency gains over foreign currency losses; (i) Net income from notional principal
contracts; (j) Amounts received under cash value insurance contracts; (k) Amounts earned by an insurance
company in connection with its reserves for insurance and annuity contracts
4 Controlling persons: Controlling persons are natural persons who exercise control over an entity. In the
case of a trust, such term means the settlor, the trustees, the protector (if any), the benefi ciaries or class
of benefi ciaries, and any other natural person exercising ultimate effective control over the trust. In the
case of a legal arrangement other than trust, such term means persons in equivalent or similar positions.
The term “Controlling Persons” shall be interpreted in a manner consistent with the Financial Action Task
Force recommendations.
5 Specifi ed US Persons Any US Person other than i). A publicly traded corporation; ii). A corporation that is a
member of the same expanded affi liate group; iii). A tax exempt organization; iv). an individual retirement plan;
v). the United States or an agency or instrumentality of the United States; vi). Any state [including District of
Columbia and United States possession] or State Authorities; vii). A bank, viii). A real estate investment trust;
ix). A regulated investment company; x). an entity registered with the SEC under the Investment Company Act
of 1940; xi). A common trust fund; xii). A tax exempt trust; xiii). A registered dealer; xiv). A registered broker
6 Expanded affi liated group: Expanded affi liated group is defi ned to mean one or more chains of members
connected through ownership (50% or more, by vote or value, as the case may be) by a common parent entity
if the common parent entity directly owns stock or other equity interests meeting the requirements in at least
one of the other members.
7 Owner documented FI: An FI meeting the following requirements:
(i) The FI is an FI solely because it is an investment entity; (ii) The FI is not owned by or related to any FI that
is a depository institution, custodial institution, or specifi ed insurance company; (iii) The FI does not maintain
a fi nancial account for any nonparticipating FI; (iv) The FI provides the designated withholding agent with all
of the documentation and agrees to notify the withholding agent if there is a change in circumstances; and
(v) The designated withholding agent agrees to report to the IRS (or, in the case of a reporting Model 1 FI,
to the relevant foreign government or agency thereof) all of the information described in or (as appropriate)
with respect to any specifi ed U.S. persons and (2). Notwithstanding the previous sentence, the designated
withholding agent is not required to report information with respect to an indirect owner of the FI that holds its
interest through a participating FI, a deemed-compliant FI (other than an owner-documented FI), an entity that
is a U.S. person,an exempt benefi cial owner, or an excepted NFE.
Defi nitions/ Instructions / Guidance
Page 2 of 2
Name: Application No.:
PAN: Folio Nos.:
A: APPLICANT/INVESTOR DETAILS:
Ultimate Benefi cial Ownership (UBO) Declaration form
(Mandatory for Non-Individual Applicants/Investors, including HUF)
I /We acknowledge and confi rm that the information provided above is/are true and correct to the best of my/our knowledge and belief and provided
after necessary consultation with tax professionals.
I / We have understood the information requirements of the application form, including FATCA and CRS requirements, terms and conditions (read
along with instructions and scheme related documents) and hereby accept the same and further confi rm that the information provided by me/us on
this form are true, correct, and complete.
Date:
Page 1 of 2
Authorized Signatories [with Company/Trust/Firm/Body Corporate seal]
B: CATEGORY [tick applicable category]:
Unlisted Company Partnership Firm LLP Unincorporated association / body of individuals Public Charitable Trust Religious Trust Private Trust/ Trust created by a Will Others _____________________ [please specify]
C: DETAILS OF ULTIMATE BENEFICIAL OWNERS (If the given space below is not adequate, please attach multiple declaration forms)
Please list below each controlling person, confi rming ALL countries of tax residency / permanent address / citizenship and ALL Tax Identifi cation Numbers for EACH controlling person. If the given rows are not suffi cient, required information in the given
format can be enclosed as additional sheet(s) duly signed by Authorized Signatories.
This declaration is NOT needed for Companies that are Listed on any recognized stock exchange in India or is a Subsidiary of such Listed Company or is Controlled by such Listed Company
S No
Name of UBO
[Mandatory]
Country of
Tax Residency
PAN / Taxpayer
Identifi cation
Number /
Equivalent ID
Number
Document Type
(Refer
Instruction 4)
% of
benefi cial
interest
Controlling
person type
Code
(Refer
Instruction 5)
Place &
Country of
Birth
[------------------------------------------------------------Mandatory ------------------------------------------------------------]
1
2
3
4
5
Date of Birth
[dd- mmm-
yyyy]
Address & Contact
details [include City,
Pincode, State, Country
Gender
[Male,
Female,
others]
Father’s Name Nationality Occupation
[------------------------------Mandatory, if PAN not provided------------------------------]
Service
Business
Others
Service
Business
Others
Service
Business
Others
Service
Business
Others
Service
Business
Others
Instructions on controlling persons / Ultimate benefi cial owner
As per SEBI Master Circular No. CIR/ISD/AML/3/2010 dated December 31, 2010 regarding Client Due Diligence policy,
related circulars on anti-money laundering and SEBI circular No. CIR/MIRSD/2/2013 dated January 24, 2013, non-
individuals and trusts are required to provide details of controlling persons [CP] / ultimate benefi ciary owner [UBO] and
submit appropriate proof of identity of such CPs/ UBOs. The benefi cial owner has been defi ned in the circular as the
natural person or persons, who ultimately own, control or infl uence a client and/or persons on whose behalf a transaction
is being conducted, and includes a person who exercises ultimate effective control over a legal person or arrangement.
1. For Investors other than individuals or trusts:
(i) The identity of the natural person, who, whether acting alone or together, or through one or more juridical
person, exercises control through ownership or who ultimately has a controlling ownership interest.
Controlling ownership interest means ownership of/entitlement to:
- more than 25% of shares or capital or profi ts of the juridical person, where the juridical person is a
company;
- more than 15% of the capital or profi ts of the juridical person, where the juridical person is a partnership;
- more than 15% of the property or capital or profi ts of the juridical person, where the juridical person is
an unincorporated association or body of individuals.
(ii) In cases where there exists doubt under clause (i) above as to whether the person with the controlling
ownership interest is the benefi cial owner or where no natural person exerts control through ownership
interests, the identity of the natural person exercising control over the juridical person through other
means like through voting rights, agreement, arrangements or in any other manner.
(iii) Where no natural person is identifi ed under clauses (i) or (ii) above, the identity of the relevant natural
person who holds the position of senior managing offi cial.
2. For Investors which is a trust:
The identity of the settler of the trust, the trustee, the protector, the benefi ciaries with 15% or more interest in the trust
and any other natural person exercising ultimate effective control over the trust through a chain of control or ownership.
3. Exemption in case of listed companies / foreign investors:
The client or the owner of the controlling interest is a company listed on a stock exchange, or is a majority-owned
subsidiary of such a company, it is not necessary to identify and verify the identity of any shareholder or benefi cial owner
of such companies. Intermediaries dealing with foreign investors’ viz., Foreign Institutional Investors, Sub Accounts and
Qualifi ed Foreign Investors, may be guided by the clarifi cations issued vide SEBI circular CIR/MIRSD/11/2012 dated
September 5, 2012, for the purpose of identifi cation of benefi cial ownership of the client
4. Document Type: Please mention the Code or Document as per table below
Code Description
A Passport
B Election ID Card
C PAN Card
D ID Card
E Driving License
G UIDIA / Aadhar letter
H NREGA Job Card
Z Others
5. Controlling Person Type [UBO] Codes: Please mention the Code as per table below
CP Type Code Description
C01 CP of legal person - ownership
C02 CP of legal person - other means
C03 CP of legal person - senior managing offi cial
C04 CP of legal arrangement - trust - settlor
C05 CP of legal arrangement - trust - trustee
C06 CP of legal arrangement - trust - protector
C07 CP of legal arrangement - trust - benefi ciary
C08 CP of legal arrangement - trust - other
C09 CP of legal arrangement - trust - other - settlor equivalent
C10 CP of legal arrangement - trust - other - trustee - equivalent
C11 CP of legal arrangement - trust - other - protector equivalent
C12 CP of legal arrangement - trust - other - benefi ciary - equivalent
C13 CP of legal arrangement - trust - other - other - equivalent
C14 Unknown
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