Application for Minor Resident Indians and NRI Investors.

Investor must read Key Information Memorandum and Instructions

before completing this form. All sections to be completed in

ENGLISH in BLACK / BLUE COLOURED INK and in BLOCK LETTERS.

ICICI Prudential Child Care Fund (Gift Plan) is suitable for investors who are seeking*:

• Long Term Wealth Creation Solution

• A diversified equity fund that aims to generate capital appreciation by investing in equity and equity related securities.

*Investors should consult their financial advisers if in doubt about whether the product is suitable for them

ICICI Prudential Child Care Fund (Gift Plan)

An open ended fund for investment for children having lock-in for at

least 5 years or till the child attains age of majority (whichever is earlier)

Investors understand that their

principal will be at moderately high risk

Low

Moderately

Low

Moderately

High

Low

High

Moderate

1. EXISTING BENEFICIARY CHILD INFORMATION

If you have an existing folio no. with PAN & KYC validation, please mention your name & folio No. and proceed

Name FIRST MIDDLE LAST

Mr. Ms.

FOLIO No.

4. INVESTMENT DETAILS (Refer Instruction No. IV)

(

For Plans & Options, please see key features)

5. PAYMENT DETAILS (Refer Instruction No. III & VII)

Scheme: ICICI Prudential Child Care Fund (Gift Plan) | Plan & Option: ___________________________________________________________________________________

Mode of Payment Cheque

Funds Transfer

NEFT

RTGS

Cheque /

DD Number

BANK Same as above [Please tick () if yes]

DETAILS:

Different from above [Please tick () if it is different from above and ﬁll in the details below]

Cheque Copy

Mandatory Enclosures

(Please tick () if the ﬁrst instalment is not through cheque)

Bank Statement

Banker’s Attestation________________________________________

Name

of Bank

Account

Number

Account Type

Current

Savings

Branch

Name

Branch City

Date

Applications with Third Party Cheques, prefunded instruments etc. and in circumstances as detailed in AMFI Circular No.135/BP/16/10-11 shall be processed in accordance with the

said circular. Please read the instruction no. VII(e). Third Party Payment Declaration form is available in www.icicipruamc.com or ICICI Prudential Mutual Fund branch offices.

MANDATORY

3. BANK ACCOUNT (PAY-OUT) DETAILS OF SOLE/FIRST APPLICANT

(Please Refer to Instruction No. III)

9 Digit MICR code

11 Digit IFSC Code

Mandatory information – If left blank the application is liable to be rejected. (Mandatory to attach proof, in case the pay-out bank account is different from the

source bank account.) For unit holders opting to hold units in demat form, please ensure that the bank account linked with the demat account is mentioned here.

Enclosed (Please ):

Bank Account Details Proof Provided.

Name of Bank

Account

Number

Account

Type

Current

Savings

Branch Name

Branch City

D D M M Y Y

BROKER CODE (ARN CODE)/

RIA CODE

SUB-BROKER ARN CODE

Employee Unique

Identification No. (EUIN)

SUB-BROKER CODE

(As allotted by ARN holder)

Declaration for “execution-only” transaction (only where EUIN box is left blank) (Refer Instruction No. XIII). – 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 APPLICANT SIGNATURE OF SECOND APPLICANT SIGNATURE OF THIRD APPLICANT

In case the purchase/subscription amount Rs 10,000/- or more and your Distributor has opted to receive transactions charges, the same are deductible as applicable from the purchase/

subscription amount and paid the distributor. Units will be issued against the balance amount invested. 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.

TRANSACTION CHARGES FOR APPLICANTS THROUGH DISTRIBUTORS ONLY [Refer Instruction XIII]

DD Charges

(if applicable)

A + B

Total

Amount

Investment

Amount

#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.

2. BENEFICIARY CHILD’S INFORMATION

[Please Refer to Instruction No. II (b) & IV]

If mandatory information left blank, the application is liable to be rejected. ¥

Individual client who has registered under Central KYC Records Registry (CKYCR) has to fill the 14 digit KYC Identification Number (KIN).

NAME OF GUARDIAN (Name should be as per PAN)

Relationship with Minor applicant:

Natural guardian Court appointed guardian

PAN/PEKRN*

KYC

Id No.

KYC Proof Attached (Mandatory)

NAME OF DONOR (If different from Parent/Legal Guardian - Name should be as per PAN)

KYC Proof Attached (Mandatory)

PAN/PEKRN*

KYC Id No.

Application No.

Investors understand that their

principal will be moderately

high risk.

Investor’s name should be as per PAN

NAME

Mr. Ms. FIRST MIDDLE LAST

Enclosed (Please )

§*

KYC Acknowledgement Letter

PAN/PEKRN*

KYC Id No.

Date of Birth**

Date of Birth

DDMMYYYY

Mr. Ms. FIRST MIDDLE LAST

Mr. Ms. M/s FIRST MIDDLE LAST

QFund.in Mutual Fund India

Mutual Fund India

Mutual Fund

India

Mutual Fund

Bandra

Mutual Funds

India

Mutual Fund

6. MODE OF HOLDING : SINGLE

7. TAX STATUS [Please tick ()]

On behalf of Minor NRI Child Others (Please specify) ___________________________________

8. DEMAT ACCOUNT DETAILS (Optional - Please refer Instruction No. XII)

CDSL: Depository Participant (DP) ID (CDSL only)

NSDL: Depository Participant (DP) ID (NSDL only)

Beneficiary Account Number (NSDL only)

Correspondence Address (Please provide full address)*

Overseas Address (Mandatory for NRI Applicant)

9. CORRESPONDENCE DETAILS OF SOLE/FIRST APPLICANT:

HOUSE / FLAT NO.

STREET ADDRESS

PIN CODE

CITY / TOWN STATE

COUNTRY

HOUSE / FLAT NO.

STREET ADDRESS

COUNTRY PIN CODE

CITY / TOWN STATE

Tel.

Office Residence

Mobile

The below information is required for all applicants/guardian

Annexure I and Annexure II are available on the website of AMC i.e. www.icicipruamc.com or at the Investor Service Centres (ISCs) of ICICI Prudential Mutual Fund.

Country of Tax Residency

Tax Identification Number or

Functional Equivalent

Identification Type

(TIN or other please specify)

If TIN is not available please tick ()

the reason A, B or C (as defined below)

Reason : A B C

10. FATCA AND CRS DETAILS FOR INDIVIDUALS (Including Sole Proprietor) (Mandatory)

Non-Individual investors should mandatorily fill separate FATCA Form (Annexure II)

Guardian

Place/City of Birth Country of Citizenship / Nationality

Are you a tax resident (i.e., are you assessed for Tax) in any other country outside India? Yes No [Please tick ()]

If ‘YES’ please fill for ALL countries (other than India) in which you are a Resident for tax purpose i.e. where you are a Citizen/Resident / Green Card Holder / Tax Resident in the respective countries.

11. KYC DETAILS (Mandatory)

Occupation [Please tick ()]

Private Sector Service

Public Sector Service

Government Service

Business

Professional

Agriculturist

Retired

Housewife

Student

Forex Dealer Others (Please specify)_______________________________________________

Guardian

Gross Annual Income [Please tick ()]

Guardian

Below 1 Lac

1-5 Lacs

5-10 Lacs

10-25 Lacs

>25 Lacs-1 crore

>1 crore

OR Net worth (Mandatory for Non-Individuals) ` ___________________________ as on (Not older than 1 year)

D D M M Y Y Y Y

Others [Please tick ()]

Please tick ():

I am Politically Exposed Person (PEP)

I am Related to Politically Exposed Person (RPEP)

Not applicable

Guardian

Indian U.S. Others (Please specify) _____________________

Country of Birth

q Reason A _ The country where the Account Holder is liable to pay tax does not issue Tax Identification Numbers to its residents.

q Reason B _ No TIN required (Select this reason Only if the authorities of the respective country of tax residence do not require the TIN to be collected)

q Reason C _ Others, please state the reason thereof: ______________________________________________________________________________________________

Address Type of Guardian: Residential Registered Office Business

Please tick () if you wish to receive Annual Report or Abridged Summary via Post - (Default communication mode is E-mail) [Refer Instruction No.X(a)]

Please tick () if you wish to receive Account statement / Other statutory information via Post instead of Email [Refer Instruction No.X(b)]

Please  any of the frequencies to receive Account Statement through e-mail

: Daily Weekly Monthly Quarterly Half Yearly Annually

* Mandatory information – If left blank the application is liable to be rejected.

** Mandatory in case the Sole/First applicant is minor.

For KYC requirements, please refer to the instruction Nos. II b(5) & X

Name of Guardian/Contact Person is Mandatory in case of Minor/Non-Individual Investor.

For documents to be submitted on behalf of minor folio refer instruction II-b(2)

Please refer to instruction no. IX

Bandra West

Mutual Fund Mumbai

Mumbai

Types of Mutual Funds

I __________________________________________________________________________________________________________________________________________________ (parent/legal guardian), do hereby assign the

amount payable by ICICI Lombard General Insurance Co. Ltd., in the event of my death, to _____________________________________________________(assignee)* my __________________________________. I further

declare that his/her receipt shall be sufficient discharge by ICICI Lombard General Insurance Co. Ltd.

Dated this __________________________________ day of _________________ at ________________.

Name (Parent/Legal Guardian): _________________________________________________________________________________

Address: ____________________________________________________________________________________________________

Signature of Parent/Legal Guardian

12. ASSIGNMENT FOR INSURANCE [Please refer to the Personal Accident Insurance Cover Instruction]

* Assignee should be a resident who has attained the age of majority.

INVESTOR(S) DECLARATION & SIGNATURE(S)

The Trustee, ICICI Prudential Mutual Fund, I/We have read and understood the Scheme Information Document/Key Information Memorandum of the Scheme(s). I/We apply for the

units of the Fund and agree to abide by the terms, conditions, rules and regulations of the scheme and other statutory requirements of SEBI, AMFI, Prevention of Money Laundering

Act, 2002 and such other regulations as may be applicable from time to time.I/We confirm to have understood the investment objectives, investment pattern, and risk factors

applicable to Plans/Options under the Scheme(s). I/we have not received nor been induced by any rebate or gifts, directly or indirectly, in making this investment. 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, Regulations or any other applicable

laws enacted by the Government of India or any Statutory Authority. I/We agree that in case my/our investment in the Scheme is equal to or more than 25% of the corpus of the

plan, then ICICI Prudential Asset Management Co. Ltd.(the ‘AMC’), has full right to refund the excess to me/us to bring my/our investment below 25%. I/We hereby declare that I am/

we are not US Person(s). I/We hereby declare that I/we do not have any existing Micro SIPs which together with the current application will result in a total investments exceeding

Rs.50,000 in a year. 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 interested in receiving promotional material from the AMC via mail,

SMS, telecall, etc. If you do not wish to receive, please call on tollfree no. 1800 222 999 (MTNL/BSNL) or 1800 200 6666 (Others).

Information/documents given in/with this application form is true and complete in all respects and I/we agree to provide any additional information that may be required by the AMC/

the Fund/ Registrar and Transfer Agent (RTA). I/We agree to notify the AMC/the Fund immediately upon change in any information furnished by me.

SIGNATURE OF SOLE / FIRST APPLICANT/GUARDIAN SIGNATURE OF SECOND APPLICANT SIGNATURE OF THIRD APPLICANT

Plan

Option/Sub-option Payment Details

Amt.________________________ Cheque/DD No.

__________________ dtd:__________________

Bank & Branch_____________________________

Receiver’s Signature & Stamp

ACKNOWLEDGEMENT SLIP

(Please Retain this Slip)

Application No.



To be filled in by the Investor. Subject to realization of cheque and furnishing of

Mandatory Information.

EXISTING FOLIO NO.

Note: All future communications in connection with this application should be addressed to the nearest ICICI Prudential Mutual Fund Customer Service Centre, quoting full name of

the first applicant, the application serial number, the name of the scheme, the amount invested, date and the place of the Customer Service Centre where application was lodged.

FOR ANY ASSISTANCE OR FURTHER INFORMATION PLEASE CONTACT US

ICICI Prudential Asset Management Company Limited

Central Service Office, 2nd Floor, Block B-2, Nirlon Knowledge Park, Western Express Highway, Goregaon (East), Mumbai - 400 063. India

TOLL FREE NUMBER 1800 222 999 (MTNL/BSNL) 1800 200 6666 (OTHERS) EMAIL enquiry@icicipruamc.com WEBSITE www.icicipruamc.com

Name of the Investor: _________________________________________________________________________________________________________________________________

ICICI Prudential Child Care Fund (Gift Plan)

ACKNOWLEDGEMENT

Mutual Fund

India

Mumbai