Trading Account Number / Login ID

1 form No. / Trading Account No. / User ID - _____FATCA / crs declaration (Individuals)1. Are you a US Person Yes No 2. Country of Birth: India Other _____3. Place (City/Town) of Birth (if other than India) : _____4. Country of Residence for Tax Purpose: Other _____ (other than India)5. Tax Identification No. (US TIN) or equivalent (Other): _____[To be filled only if you are a US Person or tax resident in country other than India as per point4]6. Source of Wealth : Salary Business Gift Ancestral PropertyRental IncomePrize Money Royalty OthersDeclaration:1.

2 I hereby declare that the details furnished above are true and correct to the best ofmy knowledge and belief correct and complete. In case of any change in the abovegiven status on a future date, I undertake to inform I - Sec the same within 30 I agree that if I am a Person or tax resident of a reportable foreign jurisdiction(other than ) requiring reporting under fatca /CRS or any other laws, my accountdetails, as required under Inter Governmental Agreement (IGA)/ MultilateralCompetent Authority Agreement (MCAA) signed by Indian Government, would bereported by I-Sec to the relevant tax authority.

3 3. I hereby confirm that details as provided by me above can be shared by I-Sec withthe concerned Asset Management Companies (AMCs) or such other productproviders, to whom fatca /CRS norms are applicable, in whose schemes/ products Imay invest/transact in future through Signature_____Date _____Please note each joint holder for Mutual Fund has to submit the above declaration separately to:ICICI Securities Ltd, Manager - Sales Operations| Shree Sawan Knowledge Park, | Gr. Floor, Plot No. D-507, | Industrial Area, , Turbhe, | Near Juinagar Railway Station, Navi Mumbai 400705 MF transactions will be permitted to clients/ joint holders in new folios afterreviewing this declaration and existing KYC data and only if permitted by AMCs.

4 Who is a US person In case of individuals, Person means a citizen or resident of the United States. Persons who would qualify as US Persons could be Born in the United States, Born outside the United States of a US parent, Naturalized citizens, Green Card Holders, Tax is a Reportable Person (non US) under Common Reporting Standards (CRS)? Under Common Reporting Standards (CRS), reportable person means Tax residents of a reportable foreign jurisdiction other than [Please note that above information is provided only for quick reference tocustomers.]

5 You are requested to consult a legal/tax advisor if in doubt.