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KRA Modification Form Individual

This document is a KYC common updation form for an individual's demat account. It contains sections for updating personal details like name, date of birth, address proof, and contact details. The form requires signatures and identity proof documents to verify the individual and update their Know Your Client details. It acknowledges receipt of the form and notes the request will be processed within 7 days.

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NiN Society
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© © All Rights Reserved
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Download as PDF, TXT or read online on Scribd
0% found this document useful (0 votes)
1K views6 pages

KRA Modification Form Individual

This document is a KYC common updation form for an individual's demat account. It contains sections for updating personal details like name, date of birth, address proof, and contact details. The form requires signatures and identity proof documents to verify the individual and update their Know Your Client details. It acknowledges receipt of the form and notes the request will be processed within 7 days.

Uploaded by

NiN Society
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
  • KYC Form Details: Gathers personal, contact, proof of identity, and current address details for KYC compliance.
  • Important Points: Provides important information regarding KYC requirements and form submission guidelines.
  • Account Holder Declaration: Collects declarations and signatures from account holders for compliance with FATCA/CRS regulations.

Kotak Securities Ltd.

Kotak Infinity, 8th floor, Building No 21, Infinity Park, Off Western Express Branch Inward Details
Highway, Gen A. K. Vaidya Marg, Malad (E), Mumbai - 400097. Recd. on
Note:- �In case of multiple holders, please fill up separate forms Emp. Name
KRA KYC COMMON UPDATION FORM A - INDIVIDUAL �All holder(s) signature proof required for E-mail/Mobile updation
Emp. ID
Trading code Demat Account No. DP ID: IN300214 Emp. Sign
Date D D / M M / Y Y Y Y KNOW YOUR CLIENT (KYC) NEW CHANGE REQUEST Branch Name
Please fill this form in ENGLISH and in BLOCK [Link] tick the appropriate now where CHANGE/CORRECTION is required IDENTITY DETAILS MANDATORY
*FATCA Declaration: I/we confirm that our Country of Birth/Nationality/ Citizenship/ Tax Residency/ Address/ Telephone No./ Address of POA or Mandate holder
is of India Yes No (if answer to your question is ‘No’, then please provide complete FATCA Declaration available on page 5 & 6)

Name _______________________________
1. PERSONAL DETAILS (Please refer instruction A)

Name*(same ID prof.)

Nationality* Date of Birth* D D / M M / Y Y Y Y C- PAN Card


Maiden Name (if any*)
Father/Spouse Name* Mother Name*
Gender* M-Male F-Female T- Transgender Marital Status* Married Unmarried Others ___________
PHOTOGRAPH
Residential Status* Resident Individual Foreign National Non Resident Indian Person of Indian Origin

3rd Holder
Occupation Type* S-Service ( Private Sector Public Sector Government Sector)
O-Others ( Professional Self Employed Retired Housewife Student) Signature
B-Business Agriculturist Forex Dealer Others ________________________
Please Specify across photograph

C
I. Certified copy of OVD or equivalent e-document of OVD or OVD obtained through digital
2. PROOF OF IDENTITY AND ADDRESS (Please refer instruction B) KYC process needs to be submitted (anyone of the following OVDs)

KRA AADHAR NON KRA & NON AADHAR


FA-Passport No. Passport Expiry Date D D / M M / Y Y Y Y

Name __________________________________
FB-Voter ID Card
FC-Driving Licence Driving Licence Expiry Date D D / M M / Y Y Y Y
FD-NREGA Job Card
FE-National Population Register Letter
FF-Proof of Possession of Aadhaar/ VID (Virtual ID) /
FE-KYC Authentication
FOffline verification of Aadhaar
Address: Line 1* _______________________________________________________________________________________________________
Line 2 ______________________________________________________________________________________________________________

2nd Holder
Line 3 ___________________________________________________ Landmark (If any) _____________________________________________
City /Town /Village*____________________________________________________________________ District*__________________________
Pin Code*_______________________________ State/U.T*____________________________________ Country*_________________________

C
I. Certified copy of OVD or equivalent e-document of OVD or OVD obtained through digital KYC process needs to be
3. CURRENT ADDRESS DETAILS (Please refer instruction B) submitted (anyone of the following OVDs)

KRA

AADHAR NON KRA & NON AADHAR FSame as above mentioned address (In such cases address details as below need not be provided)

FA-Passport No. Passport Expiry Date D D / M M / Y Y Y Y


FB-Voter ID Card
FC-Driving Licence Driving Licence Expiry Date D D / M M / Y Y Y Y Name __________________________________
FD-NREGA Job Card
FE-National Population Register Letter
FF-Proof of Possession of Aadhaar/ VID (Virtual ID) /
FE-KYC Authentication
FOffline verification of Aadhaar
FDeemed Proof of Address - Document Type ________________________________________________________________________________
Address: Line 1* _______________________________________________________________________________________________________
Line 2 ______________________________________________________________________________________________________________
Line 3 ___________________________________________________ Landmark (If any) _____________________________________________
1st Holder

City /Town /Village* ____________________________________________________________________ District* _________________________


Pin Code*_______________________________ State/U.T*____________________________________ Country*_________________________
C

ACKNOWLEDGEMENT
Date D D / M M / Y Y Y Y
Address Yes No CRM Query ID 1 From __________________________
Yes No CRM Query ID 2 having Trading Code
Mobile No./Phone No.
Client Id
Email Id Yes No CRM Query ID 3
For Kotak Securities Ltd.
Name of the Employee __________________________________________ Employee Code _______________ (Company Seal) Employee Signature
C
Your request will be processed within a tentative period of 7 days from the date of receipt of complete documents. In case of queries regarding the status of the request,
We request you to call on Customer Service No.1800 209 9191 / 1860 266 9191. Demat related complaints write at [Link]@[Link] for any other queries or complaints
write at [Link]@[Link]. 1
Kotak Securities Ltd. Kotak Infinity, 8th floor, Building No 21, Infinity Park, Off Western Express
Highway, Gen A. K. Vaidya Marg, Malad (E), Mumbai - 400097.

4. CONTACT DETAILS (Please refer instruction C) (All communications will be sent on provided Mobile no. / Email-ID)

Tel.(Res.) 9 1 S T D - Mobile 9 1 -

Tel.(Off.) 9 1 S T D - Fax 9 1 S T D -

E-mail ID. SMS Flag Yes No


The mobile number mentioned here belongs The E-Mail ID mentioned here belongs
to Name of relative ____________________________ to Name of relative ___________________________________________________
Self Spouse Dependent parent Self Spouse Dependent parent
Dependent children PAN of relative Dependent children PAN of relative

APPLICANT DECLARATION

• I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you of any changes therein,
immediately. In case any of the above information is found to be false or untrue or misleading or misrepresenting, I am aware that I may be held liable for it.
• I hereby consent to receiving information from Central KYC Registry through SMS/Email on the above registered number/email address.
• I/We are aware that the information on provided herewith shall be updated in accounts maintained at Kotak Securities under intimation to me.
Date ___________________________ Place ___________________________

1st Holder 2nd Holder 3rd Holder


C C C

Name ___________________________ Name ___________________________ Name ___________________________

Check list to be verified by acquiring sales staff Certified Copies Details Applicable for All Holders

Details Documents verified with original / Client Interviewed By / In-Person Verification done by

Name of the Employee / Authorised Person

Employee Code / SEBI Reg. No. / AP Reg. No.

Name & Address of Branch/Franchisee/


Service Center

Designation of the Employee

Date
Place of verification

Signature

Name of Institution Code of Institution


Stamp
Kotak Securities Ltd. NSE Code - 08081 BSE Code - 673 MSE Code - 1024 of
Institution
MCX - 56285 NCDEX - 1262

For Office Use Only Ver. 3 (Dec. 2020)

Address CRM Query ID 1 Mobile No./Phone No. CRM Query ID 2

Email Id CRM Query ID 3

Application Type* Update

KYC Number (To be filled by (Mandatory for KYC update request)


financial institution)
Account Type* Normal Minor Aadhaar OTP Based E-KYC (in non-face to face mode)
Document Received Certified Copies E-KYC data received from UIDAI
Data received from Offline verification Digital KYC Process
Equivalent e-document Video Based KYC

2
Kotak Securities Ltd. Kotak Infinity, 8th floor, Building No 21, Infinity Park, Off Western Express Branch Inward Details
Highway, Gen A. K. Vaidya Marg, Malad (E), Mumbai - 400097. Recd. on
Note:- In case of multiple holders, please fill up separate Emp. Name
KRA KYC COMMON UPDATION FORM B - INDIVIDUAL forms for FATCA Emp. ID
Emp. Sign
Trading code Demat Account No. DP ID: IN300214 Branch Name
Date D D / M M / Y Y Y Y
Please fill this form in ENGLISH and in BLOCK [Link] tick the appropriate now where CHANGE/CORRECTION is required IDENTITY DETAILS MANDATORY
*FATCA Declaration: I/we confirm that our Country of Birth/Nationality/ Citizenship/ Tax Residency/ Address/ Telephone No./ Address of POA or Mandate holder
is of India Yes No (if answer to your question is ‘No’, then please provide complete FATCA Declaration available on page 5 & 6)

Name _______________________________________________________________________________________________________________________________________

Gender* M-Male F-Female T- Transgender Date of Birth* D D / M M / Y Y Y Y

1. REQUEST FOR BANK DETAILS UPDATION/RTGS FACILITY Change Addition (Only for trading) CRM Query ID 5
I want to avail RTGS/NEFT Facility: Yes No Default mapping Yes No
Bank Name __________________________________________________________________________________________________________________________________
Branch Address____________________________________________________________________________City ___________________ Pin Code
IFSC Code of beneficiary bank MICR Code :
Bank A/c No. ________________________________________________________________________________________________Bank A/c Type : Saving Current
Full name of First Holder in the Bank _____________________________________________________________________________________________________________
Full name of Second Holder in the Bank ___________________________________________________________________________________________________________
Full name of Third Holder in the Bank _____________________________________________________________________________________________________________
I am enclosing the following documents as proof that the aforesaid account belongs to me:
1. Cancelled personalized cheque leaf of the above mentioned Bank Account and 2. Bank statement/Bank Passbook copy of the same.
3. In case Bank Account in Joint Name NOC from Account holder is required. A/c Type : Online Offline Bank Name: KMBL Other Bank
In case Existing Bank a/c is being replaced with KMBL A/c then read the Point # “E” given in “Instruction / Check List for Filling KYC Form”

2. Mode of Receiving Statement of Account [Tick any one] Please refer instruction D CRM Query ID 6

Physical Form Electronic Form (Read the point #‘D’ and ensure that email id is provided in KYC application form)

[Link] Form for Accepting Contract Notes and other Communication through Electronic mode and on Mobile Phone: (Only for trading)
Email ID: _______________________________________________________________ Mobile 9 1 - CRM Query ID 7
I/We hereby agree to receive: (Please tick any one) Contract notes and other communication on Email and mobile
Contract notes and other communication through physical mode*
Please send all communication at my/our email id and mobile number as mentioned in the client registration form. I/ We agree that all information sent to the
abovementioned email id shall be binding upon me/us. Further, I /We understand that nonreceipt of bounced mail notification by Kotak Securities Limited (KSL) shall
amount to delivery of the contact note or such other information at my /our email id. I/We agree that KSL shall not be responsible for the non-receipt of the contract
note/confirmation note/other correspondence by me/us due to any change in the address/email id/mobile number if not intimated by me/us. I/We am/are aware that for any
change in the address/email id/mobile number, I/we am/are required to update the same to KSL in writing through a physical letter. If I/we avail online trading services
provided by KSL, the said updation can also be made through a secured access to the website.
* Nominal charges may be debited to my account as per the prevalent policy of the company towards the physical delivery of various communication
The mobile number mentioned here belongs to Name of relative _______________________________________________
Self Spouse Dependent parent Dependent children PAN of relative Client Signature
C
The email ID mentioned here belongsto Name of relative _____________________________________________________
Self Spouse Dependent parent Dependent children PAN of relative

DECLARATION
I / We hereby declare that the details furnished above are true & correct to the best of my knowledge and undertake to inform you of any changes therein immediately, and I/we may be held liable for any
information is found to be false/misreading /misrepresenting. I/We are aware that the information provided herewith shall be updated in accounts maintained at Kotak Securities under intimation to me.
1st Holder 2nd Holder 3rd Holder
C C C

Name ________________________________ Name ________________________________ Name ________________________________

ACKNOWLEDGEMENT

Date D D / M M / Y Y Y Y From __________________________


Bank Updation/RTGS Facility Yes No CRM Query ID 5 having Trading Code
Email Consent for Transaction
Statement (Only for DP) Yes No CRM Query ID 6 Client Id
Contract Note/Communication Yes No CRM Query ID 7 For Kotak Securities Ltd.
Preference (Only for Trading)
(Company Seal) Employee Signature
C
Name of the Employee __________________________________________ Employee Code ___________________
Your request will be processed within a tentative period of 7 days from the date of receipt of complete documents. In case of queries regarding the status of the request, We
request you to call on Customer Service No. 1800 209 9191 / 1860 266 9191. Demat related complaints write at [Link]@[Link] for any other queries or
complaints write at [Link]@[Link].

3
Kotak Securities Ltd. Kotak Infinity, 8th floor, Building No 21, Infinity Park, Off Western Express
Highway, Gen A. K. Vaidya Marg, Malad (E), Mumbai - 400097.

IMPORTANT POINTS :
1. Self attested copy of PAN card and all other documents are mandatory all clients and persons authorized to deal in securities onbehalf of for company / firm / others.
2. Copies of all documents submitted by the client should be verified with original by Kotak Securities employee / Registered Authorised Person. In case the original of
any document is not produced for verification, then the copies should be properly attested by entities authorized for attesting the documents, as per the below
mentioned list. List of people authorized to attest the documents: Notary Public, Gazetted Officer, Manager of a Scheduled Commercial / Co-operative Bank or
Multinational Foreign Banks (Name, Designation & Seal should be affixed on the copy). In case of NRIs, authorized officials of overseas branches of Scheduled
Commercial Banks registered in India, Notary Public, Court Magistrate, Judge, Indian Embassy /Consulate General in the country where the client resides are
permitted to attest the documents.
3. If any proof of identity or address is in a foreign language, then translation into English is required.
4. Name & address of the applicant mentioned on the KYC form, should match with the documentary proof submitted.
5. If correspondence & permanent address are different, then proofs for both have to be submitted.
6. Sole proprietor must make the application in his individual name & capacity.
7. For non-residents and foreign nationals, (allowed to trade subject to RBI and FEMA guidelines), copy of passport / PIOCard / OCI Card and over seas address proof
Is mandatory.
8. In case you submit deemed Officially Valid Document (OVD) for proof of address as your Officially Valid Document (OVD) does not contain updated address then
you are required to submit OVD or their equivalent E-document within a period of three months, failing which we may suspend your account.

General Instructions:
A) Fields marked with ‘*’ are mandatory fields.
B) Tick ‘√ ’ wherever applicable.
C) Please fill the form in English and in BLOCK letters.
D) Please fill the date in [Link] format.
E) For particular section update tick ( √ ) in the box section number and strike off the sections not required to be updated.
F) Please read section wise detailed guideliness/ instruction at the end.
G) KYC number of applicant is mandatory for update application.
H) The ‘OTP based E-KYC’ check box is to be checked for accounts opened using OTP based E-KYC in non-face to face mode.

A. Clarification / Guidelines on filling ‘Personal Details’ section


1. Name: The name should match the name as mentioned in the Proof of Identity submitted failing which the application is liable to be rejected.
2. One the following is mandatory: Mother’s name, Spouse’s name, Father’s name.

B. Clarification / Guidelines on filling ‘Current Address details’ section


1. In case of deemed PoA such as utility bill, the document need not be uploaded on CKYCR
2. POA to be submitted only if the submitted Pol does not have current address or address as per Pol is invalid or not in force.
3. State / U.T Code and Pin / Post Code will not be mandatory for Overseas addresses.
4. Regulated Entity (RE) shall redact (first 8 digits) of the Aadhaar number from Aadhaar related data and documents such as proof of possession of Aadhaar, while
uploading on CKYCR.
5. “Equivalent e-document” means an electronic equivalent of a document, issued by the issuing authority of such document with its valid digital signature including
documents issued to the digital locker account of the client as per rule 9 of the Information Technology (Preservation and retention of Information by Intermediaries
Providing Digital Locker Facilities) Rules, 2016.
6. ‘Digital KYC process’ has to be carried out as stipulated in the PML Rules, 2005.
List of documents for ‘Deemed Proof of Address’:
[Link]. Description
• Utility bill which is not more than two months old of any service provider (electricity, telephone, post-paid mobile phone, piped gas, water bill).
• Property or Municipal tax receipt.
• Pension or family pension payment orders (PPOs)issued to retired employees by Government Departments or Public Sector Undertakings, if they contain the
address.
• Letter of allotment of accommodation from employer issued by State Government or Central Government Departments, statutory or regulatory bodies,
public sector undertakings, scheduled commercial banks, financial institutions and listed companies and leave and licence agreements with such employers
allotting offical accommodation.

7. Regulated Entity (RE) shall redact (first 8 digits) of the Aadhaar number from Aadhaar related data and documents such as proof of possession of Aadhaar, while
uploading on CKYCR.
8. “Equivalent e-document” means an electronic equivalent of a document, issued by the issuing authority of such document with its valid digital signature including
documents issued to the digital locker account of the client as per rule 9 of the Information Technology (Preservation and retention of Information by Intermediaries
Providing Digital Locker Facilities) Rules, 2016.
9. ‘Digital KYC process’ has to be carried out as stipulated in the PML Rules, 2005.

C. Clarification / Guidelines on filling ‘Contact details’ section


1. Please mention two- digit country code and 10 digit mobile number (e.g. for Indian mobile number mention 91-9999999999).
2. Do not add ‘0’ in the beginning of Mobile number.

D. Mode of Receiving Statement of Account


Notes: For receiving Statement of Account in Electronic form:
I. Client must ensure the confidentiality of the password of the email account.
II. Client must promptly inform the Participant if the email address has changed.
III. Client may opt to terminate this facility by giving 10 days prior notice. Similarly, Participant may also terminate this facility by giving 10 days prior notice.

E. BANK DETAILS UPDATION/RTGS FACILITY


In case you wish to have direct Access Facility with the new Bank Account and Power Of attorney has not been registered against this Account, please submit a copy of
the “Linking Letter” to your Bank for linking the same. Please note that in absence of the same, you will be unable to transfer funds to your Trading Account.
4
Kotak Securities Ltd. Kotak Infinity, 8th floor, Building No 21, Infinity Park, Off Western Express
Highway, Gen A. K. Vaidya Marg, Malad (E), Mumbai - 400097.

FATCA / CRS DECLARATION FOR INDIVIDUAL ACCOUNTS


Note - The information in this section is being collected because of enhancements to Kotak Securities Limited’s new account on-boarding procedures in order to fully comply
with Foreign Account Tax Compliance Act (FATCA) requirements and the Common Reporting Standards (CRS) requirements pursuant to amendments made to Income-tax
Act,1961 read with Income-tax Rules, 1962. For more information refer: [Link] & [Link] (We are unable to provide advice about your tax
residency. If you have any questions about your tax residency, please contact your tax advisor)

1st Holder - Section I (All fields are mandatory) (Please fill in BLOCK LETTERS)

Details of Account Holder


1 Trading code: Client ID (To be provided only if demat account is with KSL):

2 Name of Account Holder

3 Address for Tax Residence (Other than India)


City State Country Pin Code
4 Address Type (Tick whichever applicable) (a) Residential (b) Business (c) Registered Office
(d) Residential/ Business (e) Unspecified
5 Do you satisfy any of the criteria mentioned below? Yes No
a. Citizen of any country other than India (dual / multiple) [including Green card]
b. Country of birth is any country other than India
c. Tax resident of ANY country / ies other than India
d. POA or a mandate holder who has an address outside India
e. Address or telephone number outside India
If your answer to any of the above questions is a ‘YES’, please fill Section II of the form, else go to declaration & acknowledgment

1st Holder - Section II (All fields are mandatory)

Father’s name__________________________________________________________________________________________________ (If PAN not available, then mandatory)


Country of Birth’ __________________________________________________ Place within the country of birth __________________________________________________
‘(If USA, however nationality and/or country of tax residency is not USA, please provide documentary evidence as mentioned in Instruction 1)
Source of Wealth ____________________________________ Nationality______________________________________________
Please list below the details, confirming ALL countries of tax residency/ permanent residency/ citizenship and ALL Tax Identification Numbers
$
Country of Tax residency Tax identification no Tax identification document (TIN or functional equivalent)

$
It is mandatory to supply a TIN or functional equivalent (in case TIN not available )if the country in which you are tax resident issues such identifiers. If no TIN /functional equivalent is yet available or
has not yet been issued, please provide an explanation below.

2nd Holder - Section I (All fields are mandatory) (Please fill in BLOCK LETTERS)
Details of Account Holder
1 Trading code: Client ID (To be provided only if demat account is with KSL):

2 Name of Account Holder


3 Address for Tax Residence (Other than India)
City State Country Pin Code
4 Address Type (Tick whichever applicable) (a) Residential (b) Business (c) Registered Office
(d) Residential/ Business (e) Unspecified
5 Do you satisfy any of the criteria mentioned below? Yes No
a. Citizen of any country other than India (dual / multiple) [including Green card]
b. Country of birth is any country other than India
c. Tax resident of ANY country / ies other than India
d. POA or a mandate holder who has an address outside India
e. Address or telephone number outside India
If your answer to any of the above questions is a ‘YES’, please fill Section II of the form, else go to declaration & acknowledgment

2nd Holder - Section II (All fields are mandatory)

Father’s name__________________________________________________________________________________________________ (If PAN not available, then mandatory)


Country of Birth’ __________________________________________________ Place within the country of birth __________________________________________________
‘(If USA, however nationality and/or country of tax residency is not USA, please provide documentary evidence as mentioned in Instruction 1)
Source of Wealth ____________________________________ Nationality______________________________________________
Please list below the details, confirming ALL countries of tax residency/ permanent residency/ citizenship and ALL Tax Identification Numbers

Country of Tax residency Tax identification no Tax identification document (TIN or functional equivalent)

$
It is mandatory to supply a TIN or functional equivalent (in case TIN not available )if the country in which you are tax resident issues such identifiers. If no TIN /functional equivalent is yet available or
has not yet been issued, please provide an explanation below.
5
Kotak Securities Ltd. Kotak Infinity, 8th floor, Building No 21, Infinity Park, Off Western Express
Highway, Gen A. K. Vaidya Marg, Malad (E), Mumbai - 400097.

3rd Holder - Section I (All fields are mandatory) (Please fill in BLOCK LETTERS)

Details of Account Holder


1 Trading code: Client ID (To be provided only if demat account is with KSL):

2 Name of Account Holder


3 Address for Tax Residence (Other than India)
City State Country Pin Code

4 Address Type (Tick whichever applicable) (a) Residential (b) Business (c) Registered Office
(d) Residential/ Business (e) Unspecified
5 Do you satisfy any of the criteria mentioned below? Yes No
a. Citizen of any country other than India (dual / multiple) [including Green card]
b. Country of birth is any country other than India
c. Tax resident of ANY country / ies other than India
d. POA or a mandate holder who has an address outside India
e. Address or telephone number outside India
If your answer to any of the above questions is a ‘YES’, please fill Section II of the form, else go to declaration & acknowledgment

3rd Holder - Section II (All fields are mandatory)

Father’s name__________________________________________________________________________________________________ (If PAN not available, then mandatory)


Country of Birth’ __________________________________________________ Place within the country of birth __________________________________________________
‘(If USA, however nationality and/or country of tax residency is not USA, please provide documentary evidence as mentioned in Instruction 1)
Source of Wealth ____________________________________ Nationality______________________________________________
Please list below the details, confirming ALL countries of tax residency/ permanent residency/ citizenship and ALL Tax Identification Numbers
$
Country of Tax residency Tax identification no Tax identification document (TIN or functional equivalent)

$
It is mandatory to supply a TIN or functional equivalent (in case TIN not available )if the country in which you are tax resident issues such identifiers. If no TIN /functional equivalent is yet available or
has not yet been issued, please provide an explanation below.
Declaration & Acknowledgment
I/We being the beneficial owner of the account opened / to be opened with Kotak Securities Limited(KSL) and the income credited therein, declare that the above
information and information in the submitted documents to be true, correct and updated, and the submitted documents are genuine and duly executed. I/We acknowledge
that towards compliance with tax information sharing laws, such as FATCA/CRS, the KSL may be required to seek additional personal, tax and beneficial owner information
and certain certifications and documentation from the account holder. Such information may be sought either at the time of account opening or any time subsequently. In
certain circumstances (including if the KSL does not receive a valid self- certification from me) KSL may be obliged to share information on my account with relevant tax
authorities. Should there be any change in any information provided by me I/We ensure that I/We will advise KSL promptly, i.e., within 30 days. Towards compliance with
such laws, the KSL may also be required to provide information to any institutions such as withholding agents for the purpose of ensuring appropriate withholding from the
account or any proceeds in relation thereto. As may be required by domestic or overseas regulators/ tax authorities, the KSL may also be constrained to withhold and pay
out any sums from my account or close or suspend my account(s). I/We further agree that the information provided above will be updated in all my trading/demat accounts,
if any at PAN level.I/We also understand that the account will be reported if any one of the aforesaid FATCA / CRS criteria for any of the account holders i.e. primary or joint (in
case of demat account) are met.
Client Signature (1st Holder) Client Signature (2nd Holder) Client Signature (3rd Holder)
C C C
1 1 1

Office Use Section:


Signature Verified Designation of the employee
Name of the Employee Date
Employee Code Place of Verification
Instructions to the Form
In case customer has the following Indicia pertaining to a foreign country and yet declares self to be non-tax resident in the respective country, customer to provide relevant
Curing Documents as mentioned below:
Sr. No. FATCA/ CRS Indicia observed (ticked) Documentation required for Cure of FATCA/ CRS indicia
1 U.S. place of birth 1. Self-certification that the account holder is neither a citizen of United States of America nor a resident for tax purposes;
2. Non-US passport or any non-US government issued document evidencing nationality or citizenship (refer list
below); AND
3. Any one of the following documents:
- Certified Copy of “Certificate of Loss of Nationality or
- Reasonable explanation of why the customer does not have such a certificate despite renouncing US citizenship; or
- Reason the customer did not obtain U.S. citizenship at birth
2 Residence/mailing address in a country other than India or 1. Self-certification that the account holder is neither a citizen of United States of America nor a tax resident of any
country other than India; and
Telephone number in a country other than India 2. Documentary evidence (refer list below)
Standing instructions to transfer funds to an account maintained 1. Self-certification that the account holder is neither a citizen of United States of America nor a tax resident of any
3 country other than India; and Documentary evidence (refer list below)
in a country other than India (other than depository accounts)
4 POA granted to a person with an address in a country outside 1. Self-certification that the account holder is neither a citizen of United States of America nor a tax resident for tax
India purposes of any country other than India; OR
2. Documentary evidence (refer list below)
List of acceptable documentary evidence needed to establish the residence(s) for tax purposes:
1. Certificate of residence issued by an authorized government body*
2. Valid identification issued by an authorized government body* (e.g. Passport, National Identity card, etc.)
* Government or agency thereof or a municipality of the country or territory in which the payee claims to be a resident.
6

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