Modification Request Form

The Officer Incharge, Date ______________ Asit C Mehta Investment Interrmediates Ltd, Nucleus House, Saki Vihar Road, Andheri (East), Mumbai: - 400 072. Tele Phone: - 022-2858 3660/4444 DPID: - 13200 Fax No: - 022-2857 7647 SEBI Reg.No.IN-DP-CDSL-28-99 Email: - customerservice@acm.co.in Welcome Desk Department

Dear Sir,

Trading Code DP ID 12013200 BO ID

I request you to effect the following changes in client details. I/ We have submitted the documents (for Address Change, Bank change and Nomination Change requests) mentioned overleaf in original and photocopy required for effecting the same. # I have read and understood the instructions given overleaf.

Account Holder’s Details Name Signature

First/Sole Holder

Second Holder

Third Holder

Attach an annexure with signature if the space is insufficient

Address

Correspondence Yes No Addition Permanent Yes No

Bank Details Yes No Default Bank Yes No

Account Number Yes No Modification

MICR Code Yes No

IFSC Code Yes No

Deletion Others (Please Specify) ___________________________ Yes No

# Please mention the detail that needs to be Added/Modified/Deleted

Old Details New Details

# Please arrange to make the following changes in the records of

Demat Account Trading Account Commodities

IPO Mutual Fund Currency Trading/IRFT

FOR OFFICE USE ONLY (Mandatory to be filled by branch official) Branch/BA Name: _______________________________ Received on: ______________________________ Customer Signature Verified by (sign): ________________________________________________________ Demat Account Modified Trading Account Modified Maker ACMCode & Sign : _______________ Maker ACMCode & Sign : _____________ Checker ACMCode & Sign : _______________ Checker ACMCode & Sign :_____________ Date : ___________ Date : _____________ Rejection Reason: ___________________________________________________________________

ACKNOWLEDGEMENT ------------------------------------------------------------------------------------------------------------------------------- Received Modification Request Form as per details given below:

Trading Code Date

DP ID BO ID

First Holder Name

Second Holder Branch Name

Third holder DP Seal & Signature:

# Following are the terms/ instructions for Modification Request • Changes requested above would be effected within a period of 48 hours of receipt at Head Office. • The fresh/ new Signature(s) and/ or DP Operating Instructions would be valid once the changes are updated in the system. The company will not be responsible for return/ dishonor of any such old outstanding/ unpaid cheques/ debits/ requests and which are still in transit and yet to be received/actioned by the Asit C Mehta Investment Interrmediates Ltd. and not in conformity with the fresh/ new Signature(s) and/ or Operating Instructions Change request. I/ We have read, understood and are agreeable to the terms mentioned above. # Instructions for Branch/Business Associates: -

• It is compulsory to give acknowledgment copy to the client. • Please verify all documents with original copy • Please check that the documents submitted are not outdated • Please check that the application is complete and customer fills in parameters that are

mandatory. • Please ensure that the documents submitted are stamped with Verified With Original and In

Person Verification. • Please ensure that the documents submitted by customer are dispatched on time. • Please ensure that the documents submitted are self attested by client.

Documents requirements are: - 1) Change in Address • Modification Request Form duly signed by all the holders. • Proof of Address

Electricity bill, Telephone bill (Not more than TWO months old) Bank verification letter Pass Book Bank statement, with latest transaction (Not more than FOUR months old) with cancelled chq

having pre-printed Client Name and bank IFSC code and MICR Code• Identity Proof (Pan card, Election card, Valid Driving license, Valid Passport)

2) Change in Bank details • Modification Request Form duly signed by all the holders • Proof of Bank details

Bank verification letter/ Pass Book Bank statement with latest transaction (Not more than FOUR months old) with cancelled chq

having pre-printed Client Name and bank IFSC code and MICR Code, signature should be same, as client had signed in Account Opening Form.

Identity Proof (Pan card, Election card, Valid Driving license, Valid Passport) 3) Change in Nomination • Modification Request Form duly signed by all the holders. • Nomination form. 4) Change in Signature: In above case we request account holder to submit the bank attestation from the bank, which is registered with us. This attestation should be done on the Modification Request Form.