Service Request No.

Date :

Stay Connected
(Update your latest contact details/Address/PAN/Date of Birth/ AadharNumber For Resident Individuals)

Customer Details: Customer ID

Bank Account: Demat Account:

I-direct Account: Credit Card:

Loan: ICICI Prudential Policy:

(Please fill in all the details in CAPITAL LETTERS and use BLACK INK only. Fields with(*) are mandatory)
Page 1 of 2

* Name: Mr./Ms./Mrs./Dr.
(Primary Applicant): First Name Middle Name Last Name
Customer Declaration:Please update my/our records with your bank for the accounts that are held by me/us. Please tick the appropriate mailing address
New Communication Address:

City: State:

Pin code: Tel No. (res.):

Tel No. (off): *Mobile No:

ICICI/RSPPG/V3/0217/LIAB/STAYCONNECTED

I confirm having checked my mobile number and I also authorise the bank to contact me on the above mentioned number for
verification call back or checks to confirm the veracity of any transaction, as deemed fit by the bank. I confirm that the said mobile
number is held by me and is not in use by any third party
*E-mail ID :
I wish to register for E-mail statement : Yes No
*If your new communication address is different from your permanent address, please give the details below:
Permanent Address:

City: State:

Pin code: Tel No. (Res.):

Tel No. (off.):

# For change of address, please submit relevant address proof which will be verified with the original by officials.
(A) I wish to update details in my ICICI Prudential policy number: Yes No
(B) Date of Birth:

PAN Updation: Please update my PAN in the above mentioned account.(The copy of PAN
as document proof is enclosed for the Bank's records)
(D) Passport Number:
(E) Unique Identification number (Aadhar) Updation: Please update my Aadhar Number
in the above mentioned saving bank account. (The copy of Unique ID card as document proof is required)
1. I authorize Unique Identification Authority of India (UIDAI) to release my demographic details (Including e-mail id and
mobile number) to ICICI Bank through biometric authentication which ICICI Bank may use for KYC verification (In case of
KYC)
2. I understand that Aadhar card number updated in bank A/c will be shared with National Payment corporation of India
(NPCI) for receiving direct benefit transfer credits.

Checking your account balance or requesting a mini statement, banking is now easy as messaging a friend. With SMS, you can stay in touch with your
account with just a few key words. Simply SMS the following keywords to 9215676766
Bank Account : Primary Account
Balance Enquiry : IBAL
Last 3 transactions : ITRAN
Cheque Status Enquiry : ICSI Cheque No.
Stop Cheque Request : ISCR Cheque No.
Cheque Book Request : ICBR
View Presented Bills : IVIEW (space) Biller Nickname
ICICI/RSPPG/V3/0217/LIAB/STAYCONNECTED Page 1 of 2
 I/We hereby understand that:
All the particulars filled in the form are true, correct, complete and up-to-date in all respects and no information is
withheld
I/We understand that certain particulars given by me/us are required as per the operational guidelines governing
banking companies
ICICI Bank reserves the right to reject the request for updating Change of address/Mobile number/E-mail ID/PAN
updation / Aadhar Number /Mobile Banking facility for one or more of the products/services without assigning any
reason
If incomplete or inaccurate information is given, ICICI Bank, before rejecting/accepting any of the above request for
any of its products, has the right to ask for additional documents
It is my/our responsibility to inform ICICI Bank immediately if there is any change in the address/mobile number/
E-mail ID mentioned herein and to provide further information as may be required by ICICI Bank
Mobile Banking facility is not offered for jointly operated accounts
I/We confirm and undertake that I/We have read and understood the Terms and Conditions governing the mobile
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banking facility of ICICI Bank as mentioned/specified on www.icicibank.com

# I confirm that I have the necessary authority/mandate from all the joint account holders to sign this declaration on behalf of
myself and all the joint holders for all the products and services mentioned herein

Customer Signature (s) :

Signature Signature Signature

Name Name Name

ICICI/RSPPG/V3/0217/LIAB/STAYCONNECTED

*(Primary Applicant) *(Joint Applicant 1) *(Joint Applicant 2)

Branch Use Only

Declaration by Branch Official I confirm

The details match with the Bank's records

The applicant(s) signed in my presence and the signature(s) have been verified with the Bank records
Documentary proof is enclosed (If the account activation date is less than 6 months from the date of application)
All documents are verified with original and attested
Account is not Inactive / Dormant / Frozen / in Debit balance
Address change authorised
Identity proof is attached for the mobile banking facility
For ICICI prudential policy address updation, applicants address proof obtained additionally
For updation in Demat account / I-direct account
FATCA / CRS declaration collected from customer for updating non-India / foreign mobile number

SR No. raised for updating FATCA/CRS declaration (wherever applicable)_______________________________________________

Linked Bank Account No.__________________________________________________________________

Trading user ID (for ICICI Direct.com account only)___________________________________________

Bank
Employee ID: ______________________________ Seal

Signature of Bank Official: ______________________________

ICICI/RSPPG/V3/0217/LIAB/STAYCONNECTED

Acknowledgement Slip (To be filled by the Bank staff)

Date :
Received from ___________________________ Ac/ No./ Policy No. ______________________________________for change of address
contact details/e-mail/PAN/Mobile alert/Aadhar number for your:
Bank Account Demat Account ICICI Direct Credit Cards Loans ICICI Prudential policy
Bank
The necessary changes will be carried out in the Banks records only for the account mentioned above.
Seal
ICICI Bank (Branch Name):_____________________________ Signature of Bank Official: ____________________________
ICICI/RSPPG/V3/0217/LIAB/STAYCONNECTED Page 2 of 2
 Appl. No:

FATCA/CRS Declaration Form

To: ICICI Bank Limited India
Customer ID: Primary Holder Joint Holder 1 Joint Holder 2
Name:
Part I- Please ll in the country for each of the following (Applicable for all customers):
1. Country of : 2.US Person
(Refer denition at bottom)
a) Birth
b) Citizenship
c) Residence for Tax Purposes
Yes No
d) Current Residence (Overseas
Country for NRI)
Part II- Please note:
a. If in all elds above, the country mentioned by you is India and (except in case of seafarers) and if you do not have US person status,
please proceed to Part III for signature.
b. If for any of the above eld, the country mentioned by you is not India and/or if your US person status is Yes, please provide the Tax
Payer Identication Number (TIN) or functional equivalent as issued in the specic country in the table below:
i) TIN or Country of Issue
Functional equivalent(Please specify name and number)
ii) TIN or
Functional equivalent(Please specify name and number)
iii) TIN or
Functional equivalent(Please specify name and number)
c. If you satisfy the criteria mentioned in II (b) above but do not have Taxpayer Identication Number/functional equivalent, please tick the
reason for the same as given below:
I am a person resident out of India with (choose only if applicable):
Country not issuing TIN/Functional equivalent _______________________________ (mention Visa / Residence / Work permit number)
Dependent visa _________________________ (mention dependent visa number)
Student visa________________________________(mention student visa number)
Seafarer status ________________________________ (mention CDC/visa number)
Going to the country of residence for rst time ___________________________ (mention visa number. TIN/functional equivalent to be
communicated to the bank within 90 days, else account will get closed)
OR
I am a person resident in India as well as resident for tax purposes in India (Pleasealso ll Part IV self-certication)
d. In case you are declaring US person status asNobut your Country of Birth is US, please provide document evidencing Relinquishment
of Citizenship. If not available provide reason/s for not having relinquishment certicate____________________________________________
Please also ll Part IV Self-Certication.
Part III- Customer Declaration (Applicable for all customers)
(I) Under penalty of perjury, I certify that:
1.The applicant is (i) an applicant taxable as a US person under the laws of the United States of America (U.S.) or any state or political subdivision
thereof or therein, including the District of Columbia or any other states of the U.S., (ii) an estate the income of which is subject to U.S. federal income
tax regardless of the source thereof. (This clause is applicable only if the account holder is identied as a US person) or
2. The applicant is taxable as a tax resident under the laws of country outside India. (This clause is applicable only if the account holder is a
tax resident outside of India)
(ii) I understand that the Bank is relying on this information for the purpose of determining my status in compliance with FATCA/CRS. The Bank is not
able to offer any tax advice on FATCA/CRS or its impact. I shall seek advice from professional tax advisor for any tax questions.
(iii) I agree to submit a new form within 30 days if any information or certication on this form becomes incorrect
(iv) I agree that as may be required by domestic regulators/tax authorities the Bank may also be required to infom reportable details to CBDT or close
or suspend my account.
(v) I certify that I provide the information on this form and to the best of my knowledge and belief the certication is true, correct, and complete
including the taxpayer identication number / functional equivalent number of the applicant.

Signature :

Name : Date (DD/MM/YYYY) :

Part IV- Self-Certication: (Not Applicable for NRI customers except for point (b) below): To be lled only if-
(a)Any of the indicia parameters is outside India and TIN or functional equivalent is not available since not a resident for tax purpose outside India,or
(b) Country of Birth is US and US person is mentioned as No in Part I
Certication:
I conrm that I am not a US person or a resident for Tax purpose in any country other than
India, though one or more parameters suggest my relation with the country outside India.
Therefore, I am providing the following document as proof of my citizenship and / or residency Signature
Document Proof submitted (Pls tick document being submitted)
Passport Election Id Card PAN Card Driving License UIDAI Letter NREGA Job Card Govt. Issued ID Card
Note-The term United States person means:
(a) an individual, being a citizen or resident of the United States of America;
(b) partnership or corporation organized in the United States of America or under the laws of the United States of America or any State thereof;
(c) a trust if: i. a court within the United States of America would have authority under applicable law to render orders or judgments concerning substantially
all issues regarding administration of the trust; and ii. one or more U.S. persons have the authority to control all substantial decisions of the trust;
(d) an estate of a decedent who was a citizen or resident of the United States of America
Functional Equivalent of TIN includes the following:
A social security/insurance number, citizen/personal identication/services code/national identication number, a resident / population registration
number, Alien card number, etc.
ICICI/RSPPG/V3/0217/LIAB/STAYCONNECTED Page 3 of 3