PAN BASED MANDATE CUM SIP REGISTRATION FORM

[For investment through NACH (Not eligible for Minors Bank Account)]

SIP Registration-Cum-Mandate Form for SIP Application No.

Investor must read Key Scheme Features and Instructions before completing this form. All sections to be completed in ENGLISH in BLACK/BLUE INK and BLOCK LETTERS.
BROKER CODE (ARN CODE)/ SUB-BROKER ARN CODE SUB-BROKER CODE Employee Unique
RIA/PMRN CODE# (As allotted by ARN holder) Identification No. (EUIN)
#By mentioning RIA/PMRN 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.
TRANSACTION CHARGES FOR APPLICANTS THROUGH DISTRIBUTORS ONLY: 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.
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 APPLICANT SIGNATURE OF SECOND APPLICANT SIGNATURE OF THIRD APPLICANT

The Trustee, ICICI Prudential Mutual Fund, I/We have read and understood the contents of the Scheme Information Document of the following Scheme and the terms and conditions of the SIP Enrolment.
Sole/1st
FOLIO NO.
Applicant:

Registration via Existing OTM (Please mention UMRN if multiple OTMs exist in folio) [Tick to avail (3)]

Scheme: ICICI PRUDENTIAL __________________________________________________________ PLAN: ________________________________

SIP TOP UP (Optional)
OPTION: _____________________________ SUB-OPTION: ______________________ IDCW* FREQUENCY: ____________________________ (Tick to avail this facility)
(Refer point no. 20 under Terms and Conditions for details)
*(IDCW - Income Distribution cum capital withdrawal option)
Please refer instructions and Key Scheme Features for options, sub-options and other facilities available under each scheme of the Fund. Percentage: 10% 15% 20%
Each SIP Amount: Rs. In words: ____________________________________________________ other_____________ (multiples of 5% only)
SIP Frequency: Daily (Only business days) Weekly*** (________________) Fortnightly** Monthly Quarterly* TOP UP Amount: Rs.___________________
*In case of Quarterly SIP, only Yearly frequency is available under SIP TOP UP. **Fortnightly is available on 1st and 16th SIP Installments^ * TOP UP amount in multiples of Rs.100 only.
of each moth, as applicable. ***investors can choose any day of the week from Monday to Friday to register under weekly
frequency. #In case the choosen date is a non-business day, the transaction would be processed on the next business day. Frequency: Half Yearly Yearly
^Number of installments have to be mentioned only in case of Daily/Weekly/Fortnighly frequencies. [Refer T&C no.12(f)]
SIP TOP UP CAP Amount:
SIP SIP Start SIP End Rs.____________________________ OR
D D Month/Year M M Y Y Y Y Month/Year M M Y Y Y Y
Date#:
Month-Year#:
EXISTING OTM / FIRST INSTALLMENT BANK DETAILS:
M M Y Y Y Y
Cheque/DD No._____________________ Cheque/DD Amount Rs. __________________________ A/c No. ______________________________ #
Investor has to choose only one option – either
Bank Name: ______________________________________________________________________________________________________________ CAP Amount or CAP Month-Year

DEMAT ACCOUNT STATEMENT DETAILS (OPTIONAL – PLEASE REFER INSTRUCTION NO. 19)

NSDL: Depository Participant (DP) ID (NSDL only) Beneficiary Account Number (NSDL only) CDSL: Depository Participant (DP) ID (CDSL only)

(Please sign overleaf)

ACKNOWLEDGEMENT SLIP Folio No./ Application No.

(To be filled in by the investor)

Name of the Investor:_____________________________________________________________________________________________________________________________________

Acknowledgement Stamp
Scheme: ________________________________________________ SIP Amount Rs.________________________ SIP Frequency: Daily Weekly Fortnightly
Monthly Quarterly

SIP TOP UP Amt. Rs. ________________________ TOP UP CAP: Amt: Rs. ________________________ OR Month-Year: M M Y Y Y Y

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Mandatory fields in OTM form as per NPCI: • Mandate Date is Mandatory • Transaction type to be selected • Only one Account type to be selected • Bank account
number and Bank name • Please mention IFSC Code (11 Alpha numeric Characters) / MICR Code (9 Numeric) • Maximum amount to be mentioned (should be same
in figures and words) • valid PAN • OTM start date & end date • Name & Signature(s) as per bank records • Mandate Date and the Validity of the mandate should be
mentioned in DD/MM/YYYY format • Mandate start (From) date should be after Mandate (Application) date. • Maximum duration of this mandate is 40 Years.
GENERAL INSTRUCTIONS
UMRN (Unique Mandate Reference Number) is provided by NPCI, which is assigned to every mandate that has been submitted to them.
Investor will not hold ICICI Prudential Mutual Fund, its registrars and other service providers responsible if the transaction is delayed or not effected or the investor bank
account is debited in advance or after the specific SIP date due to various clearing cycles.
The Bank & AMC shall not be liable for, nor be in default by reason of, any failure or delay in completion of its obligations under this Agreement, where such failure or
delay is caused, in whole or in part, by any acts of God, civil war, civil commotion, riot, strike, mutiny, revolution, fire, flood, fog, war, lightening, earthquake, change of
Government policies, unavailability of Bank’s computer system, force majeure events, or any other cause of peril which is beyond the Bank’s reasonable control and
which has effect of preventing the performance of the contract by the Bank.
The investor hereby agrees to indemnify and not hold responsible, AMC/Mutual Fund (including its affiliates), and any of its officers directors, personnel and employees,
the Registrars & Transfer (R&T) agent and the service providers incase for any delay/wrong debits on the part of the bank for executing the debit mandate instructions
for any sum on a specified date from your account. If the transaction is delayed or not effected at all for reasons of incomplete or incorrect information, the investor would
not hold the user institution responsible. Investor confirm to have understood that the introduction of this facility may also give rise to operational risks and hereby take
full responsibility.
Registration of OTM/PAN BASED MANDATE FACILITY: As an investor I/we hereby request you to register me/us for availing the facility of OTM/PAN based mandate
and carrying out transactions of additional purchase/redemption/switch in my/our folio through Call Centre and/or also authorize the distributor(s) to initiate the above
transactions on my/our behalf. In this regard, I/we also authorize the AMC, on behalf of ICICI Prudential Mutual Fund (Mutual Fund) to call/email on my/our registered
mobile number/email id for due verification and confirmation of the transaction(s) and such other purposes. The mobile number provided in the common application form
will be used as registered mobile number for verification and confirmation of transactions. If the transaction is delayed or not effected at all for reasons of incomplete or
incorrect information or non-confirmation/ verification of the transaction due to any reason, I/we shall not hold AMC, Mutual Fund, its sponsors, representatives, service
providers, participant banks responsible in this regard. 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. I/We hereby confirm that the information/documents provided by me/us in this form are true, correct and complete
in all respect. I/We hereby agree and confirm to inform AMC promptly in case of any changes. 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).
Maximum Amount: The MAXIMUM AMOUNT is the per transaction maximum limit. Investor can register multiple SIPs but the amount should not exceed the maximum
amount mentioned per transaction.

INSTRUCTIONS FOR EXISTING OTM AND PAN BASED MANDATE FACILITY

1) Investor can transact through OTM facility registered for the PAN in the respective folio(s).
2) If more than one bank accounts are registered for OTM facility, investor is requested to mention the bank account number and bank name
from where amount is to be debited. If the same is not mentioned or no OTM mandate is registered for the given bank details, AMC reserves
the right to initiate the debit through any of the valid OTM’s registered or reject the request.
3) The units shall be allotted based on the day on which funds are credited to AMC’s collection account by the service provider/ bank. This is
subject to compliance with the time stamping provision as contained in the SEBI (mutual funds) regulations, 1996.
4) Registration request or any other subsequent transaction may be liable for rejection, if the frequency for the registered OTM is other than
“As and when presented” and/ or if the transaction 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.
6) PAN based mandate will be mapped to all the folios wherever investor is the Sole/First holder subject to completion of mandate registration
with the banker.
7) PAN based mandate will not be applicable, if bank details provided is for Minor’s Account.
8) Investor can transact using this mandate, within the limit of maximum amount and tenure specified.
9) Mandate start (From) date should be after Mandate (Application) date.

YOUR CONFIRMATION/DECLARATION: 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 as described in the Instruction No.IV(d) of the common application form. 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. 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.

Signature(s) as per ICICI Prudential Mutual Fund Records (Mandatory)

2nd Holder

3rd Holder
Sole/First
Holder

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 TERMS AND CONDITIONS
SIP Payment through NACH 17. For minimum application amount to be invested in SIP, risk factors, features,
load structurees, etc. please refer to the scheme related documents available
1. The bank account provided for NACH should be participating in NACH
on www.icicipruamc.com or with any of the customer service centres of ICICI
clearing respectively.
Prudential Mutual Fund.
2. Investors can choose any preferred date of the month as SIP debit date.
18. ICICI Prudential Mutual Fund, its registrars and other service providers shall
In case the chosen date falls on a Non-Business Day or on a date which
not be responsible and liable for any damages/compensation for any loss,
is not available in a particular month, the SIP will be processed on the
damage etc. incurred by the investor. The investor assumes the entire risk of
immediate next Business Day.. In case the Debit does not take effect for
using this facility and takes full responsibility.
two consecutive times in case of Quarterly frequency and three consecutive
times in frequencies other than Quarterly. then the SIP would be liable for 19. In daily SIP frequency transaction will be processed on Business days only.
cancellation. In case any scheduled Business day is declared as Non business day by
AMC, Regulators, Government etc for any reason the said transaction will be
3. In case of SIP transaction where the mode of payment is through NACH,
processed with the next available NAV. The investor will not hold AMC/Bank
investors are not required to do an initial purchase transaction for the
liable for processing such transactions the next day.
minimum amount as applicable. However, investors are required to submit SIP
request at least 30 days prior to the date of first installment. AMC reserves 20. SIP TOP UP Facility:
the right to register the first triggered SIP installment from subsequent month With this facility, investor can opt to increase the SIP amount at regular fixed
onwards, in case the period between the time-stamping of the SIP request intervals.
and the first triggered SIP installment is less than 30 days. In case of SIP There are two type of SIP TOP-UP:
via existing OTM, investor can choose to start the SIP in 15 days after the
(1) Fixed TOP-UP.(2) Variable TOP-UP.
date of submission. In case of incomplete mandate form, AMC may initiate
remediation process to obtain incomplete details. This process may exceed Fixed TOP-UP: With this option, investor can increase SIP amount at regular
30 days and in such case it may also impact the registration of the SIP facility interval with fixed amount. Minimum TOP-UP amount has to be Rs.100 and
and subsequent installments. SIP start date shall not be beyond 100 days in multiples of Rs.100 thereof. In case of investment made in ICICI Prudential
from the date of submission of SIP application and SIP end date shall not be ELSS Tax Saver Fund, the minimum Fixed TOP-UP amount shall be Rs.500
beyond 40 years from the SIP start date. The applicant will have the right and in multiples of Rs. 500/- thereof. For said option SIP TOP-UP frequency
to discontinue SIP at any time he or she so desires by providing a written is at Half Yearly and Yearly basis. In case of Quarterly SIP, only the Yearly
request at the office of the ICICI Prudential Mutual Fund Customer Service frequency is available under SIP TOP UP.
Centres. Notice of discontinuance should be received 30 days prior to the Please view below illustration for Fixed TOP-UP:
subsequent SIP date. All terms and conditions for SIP, including Exit Load, if
• SIP Tenure: 07Jan 2015 to 07 Dec 2020 • Monthly SIP Installment: Rs. 2000/-
any, prevailing in the date of SIP enrolment/registration by the fund shall be
levied in the Scheme. • TopUp Amount: Rs.100/- • TopUp Frequency: Yearly
4. The investor agrees to abide by the terms and conditions of NACH facilities Installment From Date To Date Monthly SIP SIP Top-Up SIP Amount
of Reserve Bank of India (RBI). No(s) Installment Amount (`) with TOP-
5. Investor will not hold ICICI Prudential Mutual Fund, ICICI Prudential Asset Amount (`) UP (`)
Management Company Limited (the AMC), ICICI Prudential Trust Limited (the 1 to 12 7-Jan-16 7-Dec-16 2000 N.A 2000
Trustee), its registrars and other service providers responsible and/or liable 13 to 24 7-Jan-17 7-Dec-17 2000 100 2100
for any damages/compensation for any loss or if the transaction is delayed
or not effected or the investor bank account is debited in advance or after the 25 to 36 7-Jan-18 7-Dec-18 2100 100 2200
specific SIP date due to various clearing cycles for NACH or any other reason/ 37 to 48 7-Jan-19 7-Dec-19 2200 100 2300
fault not attributable to ICICI Prudential Mutual Fund/the AMC/ the Trustee. 49 to 60 7-Jan-20 7-Dec-20 2300 100 2400
6. ICICI Prudential Mutual Fund reserves the right to reject any application
Variable TOP-UP: With this option, investor can increase SIP amount at
without assigning any reason thereof.
regular interval, TOP-UP amount will be based on the percentage (%) opted
7. In case of “At Par” Cheques, investors need to mention the MICR No. of his/ by investor of SIP amount. For said option SIP TOP-UP frequency is at half
her actual Bank branch. yearly and yearly basis. The minimum TOP-UP percentage (%) should be 10%
8. SIPs will be registered in a folio held by a minor only till the date of the minor and in multiple of 5% thereof. Also the TOP-UP amount will be rounded off to
attaining majority, even though the instructions may be for a period beyond the nearest highest multiple of Rs.10. Please note, Variable TOP-UP facility is
that date. The facility will automatically stand terminated upon the Unit not available for investment made in ICICI Prudential ELSS Tax Saver Fund. In
Holder attaining 18 years of age. case of any ambiguity AMC reserves the right to accept / reject the application.
9. New Investor: If the investor fails to mention the scheme name in the SIP Please view below illustration for Variable TOP-UP:
Mandate Form, then the Fund reserves the right to register the SIP as per the • SIP Tenure: 07Jan 2015 to 07 Dec 2020 • Monthly SIP Installment: Rs. 2000/-
scheme name available in the main application form. Incase multiple schemes
are mentioned in the main application form, the Fund reserves the right to • TopUp percentage: 10% • TopUp Frequency: Yearly
reject the SIP request. Installment From To Date Monthly SIP SIP SIP
10. Existing Investor: If the investor fails to mention the scheme name in the SIP No(s) Date SIP Top-Up Top-UP Amount
Mandate Form, the Fund reserves the right to register the SIP in the existing Installment Amount round off with TOP-
scheme (eligible for SIP) available in the investor’s folio. Incase multiple Amount (10%) (`) Amount UP (`)
schemes or Equity Linked Savings Scheme (ELSS) are available in the folio, (`) (`)
the Fund reserves the right to reject the SIP request. 1 to 12 7-Jan-16 7-Dec-16 2000 N.A N.A 2000
11. In case the SIP date is not mentioned/not legible, then the SIP will be 13 to 24 7-Jan-17 7-Dec-17 2000 200 200 2200
registered on 10th (default date) of each Month/Quarter, as applicable.
25 to 36 7-Jan-18 7-Dec-18 2200 220 220 2420
12. a) Minimum number of installments for daily, weekly, fortnightly and monthly
37 to 48 7-Jan-19 7-Dec-19 2420 242 240 2660
frequencies will be 6 and for Quarterly frequency minimum number of
installments will be 4. 49 to 60 7-Jan-20 7-Dec-20 2660 266 270 2930
b) Investors can choose any day of the week from Monday to Friday to Investor can either opt for Fixed Top-up facility or Variable Top-up facility
register under weekly frequency. Incase Day is not specified by the under SIP Top-up. In case, Investor opts for both the options, than Variable
investor transaction will be processed on wednesday. top-up feature shall be triggered. In case the TOP UP facility is not opted
c) For Fortnightly frequency, the transaction will be processed on 1st and 16th by ticking the appropriate box and/or frequency is not selected, the TOP
day of each month, as applicable. UP facility may not be registered.
d) For Monthly and Quarterly frequencies, the transaction will be processed In a scenario where investor selects multiple % option under variable SIP
on any day basis. Top-up plan, higher percentage will be considered.
e) Incase the SIP Day/Date selected is a non-business day the transaction Other Information:
will be processed on the next business day. SIP TOP UP will be allowed in Micro SIP folio subject to condition that total
f) In case both SIP end date and number of installments are mentioned in investment including SIP TOP UP does not exceed Rs. 50,000/- in a rolling
the SIP application for Daily, weekly and fortnightly frequency then SIP 12 month period or financial year i.e. April to March, the limit on Micro SIP
shall get registered as per the number of installments provided. investments.
13. If the investor selects multiple SIP frequencies or fails to choose any of them, The investor agrees to avail the TOP UP facility for SIP and authorize his/her
the default SIP frequency will be Monthly. bank to execute the NACH/SI for a further increase in installment from his/her
14. If the investor has not mentioned the SIP start month, SIP will start from the designated bank account.
next applicable month, subject to completion of 30 days lead time from the SIP TOP-UP CAP:
receipt of SIP request. (i) Cap Amount: Investor has an option to freeze the SIP Top-Up amount once
15. In case End date mentioned on SIP form, falls beyond the date mentioned it reaches a fixed predefined amount. The fixed pre-defined amount should
in Mandate form, then SIP shall be registered as per date mentioned on be same or lesser than the maximum amount mentioned by the investor
mandate. Incase SIP “end Month/Year” is incorrect or not mentioned by the in the bank mandate. In case of difference between the Cap amount &
investor in the SIP form then AMC reserves the right to consider the SIP end the maximum amount mentioned in bank mandate, then amount which
date as five years from the start date as default. is lower of the two amounts shall be considered as the default amount
16. Existing investors have to provide their folio numbers. of SIP Cap amount

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 (ii) Cap Month-Year: It is the date from which SIP Top-Up amount will cease
and last SIP installment including Top-Up amount will remain constant
from Cap date till the end of SIP tenure.
Investor shall have flexibility to choose either Top-Up Cap Amount OR
Top-Up Cap Month-Year. In case of multiple selection, Top-Up Cap Amount
will be considered as default selection.
In case of non selection, the SIP variable Top-Up amount will be capped
at a default amount of Rs.10 lakhs.
SIP amount will remain constant from Top-Up Cap date/amount till the end
of SIP Tenure.
21. In case of application is received for change of scheme / change of bank and
the existing SIP is registered beyond 40 years from the date of application
the SIP end date will be modified accordingly as per end date mentioned in
the new mandate (with maximum validity of 40 years)
22. DEMAT/NON-DEMAT MODE:
Investors have an option to hold the Units in dematerialized form. By providing
DP details, Units shall be directly credited to the investor’s demat account after
the realization of funds and depositories will issue a statement. Applicants
must ensure that the sequence of names as mentioned in the application form
matches with that of the account held with the Depository Participant.
If the details mentioned in the application are incomplete/incorrect or not
matched with the Depository data, the application shall be treated as invalid
and the units would be allotted in Non- Demat mode.The application form
should mandatorily accompany the latest Client investor master/ Demat
account statement. Demat option will be not be available for Daily/Weekly/
Fortnightly IDCW options. Investors desiring to get allotment of units in demat
mode must have a beneficiary account with a Depository Participant (DP) of
the Depositories i.e. National Securities Depositories Limited (NSDL) / Central
Depository Services Limited (CDSL).
Allotment letters would be sent to investors who are allotted units in Demat
mode and a Statement of Accounts would be sent to investors who are allotted
units in Non-Demat mode. Investors are requested to note that Units held in
dematerialized form are freely transferable except units held in Equity Linked
Savings Scheme’s (ELSS) during the lock-in period.
The units will be allotted based on the applicable NAV as per the Scheme
Information Document (SID). The investors shall note that for holding the
units in demat form, the provisions laid in the SID of respective Scheme and
guidelines/procedural requirements as laid by the Depositories (NSDL/ CDSL)
shall be applicable. In case the unit holder wishes to convert the units held in
non-demat mode to demat mode or vice versa at a later date, such request
along with the necessary form should be submitted to their Depository
Participant(s). Units held in demat form will be freely transferable, subject to
the applicable regulations and the guidelines as may be amended from time
to time.
Reinvestment of Payout of Income Distribution cum capital withdrawal
option: In case Unitholder has opted for Payout of Income Distribution cum
capital withdrawal option option under weekly, fortnightly, monthly, quarterly,
half yearly and annual frequencies, as applicable in the respective schemes,
there will be minimum amount for Payout of Income Distribution cum capital
withdrawal option, as per the provisions of the respective scheme, else the
IDCW would be mandatorily reinvested. The IDCW would be reinvested in the
same Scheme/ Plan by issuing additional Units of the Scheme at the prevailing
ex-IDCW Net Asset Value per Unit on the record date. There shall be no exit
load on the redemption of units allotted as a result of such reinvestment of
IDCW. It may also be noted that the criteria for compulsory reinvestment
of IDCW declared under the Payout of Income Distribution cum capital
withdrawal option option in specific schemes, where the IDCW amount is
less than the minimum Payout of Income Distribution cum capital withdrawal
option limit, will not be applicable to investors holding their units in DEMAT
form. For unit holders, holding units in DEMAT form, if IDCW is declared in
any applicable Scheme, the amount will be paid out or reinvested as per the
option selected by the unit holders only. IDCW declared will be compulsorily
paid out under the “Payout of Income Distribution cum capital withdrawal
option” option of all schemes which have discontinued fresh subscriptions with
effect from October 1, 2012 as per Notice-cum-Addendum no.017/09/2012
published on October 01, 2012.