Modification Form

(Kindly fill the form in Capital Letters only)

Date Siebel Request No.

For Bank Use:

Customer Account Type:
Wealth Privy Resident Individual Non-Individual Non Resident

CRN Corporate CRN

CASA Account Number Investment account Investment A/c No.

Demat Client ID Credit Card Credit Card No.

Merchant Acquiring Services MID TID

I/We

Request you to update your records as per the details provided below.
To update

Name*

Office / Indian (in case of NRI/PIO) Address. Please select the below Options

Please tick if your Office address is same as your mailing address (where all communications will be sent)

Change to be done at CRN level (i.e. for all the relationships with the bank) Change to be done at above mentioned Account level

Flat Number/Building

Residence / Overseas (in case of NRI / PIO) Address / Registered Address

Please tick if your Residence address is same as your mailing address (where all communications will be sent)

Change to be done at CRN level (i.e. for all the relationships with the bank) Change to be done at above mentioned Account level

Flat Number/Building

Telephone Number Office Residence

Mode of Operation Singly Either / Survivor Jointly Anyone / Survivor

Mobile Number ISD CODE

E-Mail address

Please sign in case changes required in Moble No. / E-mail ID

Customer’s Sign
(In case of the Non-individual, please provide Sign,

Update PAN Name & Designation with stamp of Organization)

Nomination display on Net Banking & all Customer Deliverables Yes No

Request to Correct Date of Birth (provide a valid age proof)

POS / Bharat QR Address Change. Please select the below options

Installation Address Registered Address Mailing Address

Flat Number/Building

Terminal (Model) Type change: Old Terminal Type: New Terminal Type: TID No:
Deactivation request reason

TID Number 1 : TID Number 2 :

Change in mode of Payment instructions for credit POS/QR settlement:
I would like to change my Kotak (Settlement) account to IFSC Code :

I would like to change my settlement account (Other Bank A/c Details) to :

Beneficiary Bank A/C Number Beneficiary IFSC Code

Beneficiary Bank A/C Name Branch Name & City

Beneficiary Account Type : Saving Current

Request to update the Activation of the facility : Refund Pre Auth Facility Key Entry Tip Adjustment

Request to update the Deactivation of the facility : Refund Pre Auth Facility Key Entry Tip Adjustment
Change in transaction Limit : Daily Txn Limit Per Txn Limit Monthly Txn Limit
Change in Parameter DBA Name Merchant category From To

Activation / Deactivation of Value added Services Type of Service

Contact Person Name

Contact Person Number

Request pertaining to Demat Account only : Dividend A/c Demat Charges

Bank Name :
Branch Name & Address :

Flat Number/Building

Account Number : MICR Number :

Request to Update PAN Number : Request to update Aadhaar :

Debit Authorization (Authorization for debiting the CASA A/c for bank charges & undertaking for the payment of interest in case of occurrence
of Debit Balances.)
I/We authorize the Bank to debit the said account for the applicable service charges payable by the below mentioned person also :

Sr.
No. Account Holders' Name Demat Account No.

Declaration:
I/We hereby authorize the bank to debit all types of applicable bank charges/service charges payable by me/us to Said Account/s. I/We undertake
that sufficient balances shall be maintained in the Said Accounts to facilitate the debiting of applicable Service Charges. The failure on part of
me/us to maintain sufficient balances in the Said Account shall not any way impair the right of the Bank to Debit the Service Charges. I/We
hereby further authorize the Bank to charge any interest on Debit balance in the Said Accounts due to the debiting of applicable Service
Charges. The Bank shall not be obliged to provide overdraft facility on the Said Account but for towards the debiting of applicable Service
Charges payable by us/me. I/We specifically agree and confirm that any matter or issue arising hereunder shall be governed by and constructed
exclusively in accordance with the Indian Laws and shall be subject to the jurisdiction of the courts of Mumbai in India.
I/We also undertake to intimate the Bank in case of non receipt of alerts on the Mobile number / E-mail ID provided to the Bank for receipt of
Alerts. I/We agree that the Bank shall not be held responsible for non-receipt of transaction related alert in case of a fraudulent transaction in
the my/our account/s.
I/We agree that in case of non updation of Mobile Phone Number in my account, Bank will restrict electronic transactions (e.g. NB, MB, E-
Commerce, POS) in the account and will allow only ATM cash Withdrawals.
I have voluntarily supplied the above information which I acknowledge that the Bank is required to obtain to provide its products and services
to me. I have gone through the Privacy Notice published by the Bank on its website www.kotak.com and having agreed to the same I hereby
give my consent in favour of the Bank to process my personal information for the purposes and in the manner provided in the Privacy Notice
while I avail various products and services from the Bank.

Date :
Signature(s)
1st Account Holder 1st Account Holder 1st Account Holder 1st Account Holder
(In case of Non-Individual, please provide Sign, (In case of Non-Individual, please provide Sign, (In case of Non-Individual, please provide Sign, (In case of Non-Individual, please provide Sign,
Name & Designation with stamp of Name & Designation with stamp of Name & Designation with stamp of Name & Designation with stamp of
Organization) Organization) Organization) Organization)

For Bank Use only

KMBL/Dec-2018/V 1.04

Date of Acceptance Sol ID

Receiver’s stamp
Signature verified by

Authorized by
Documents sent to CPC / RPC on
 Customer Acknowledgement
Imp Notes:
(For Individual - at Account level changes, all the account holders need to sign whereas at CRN level changes, respective CRN holder has to sign
For Non-Individual, signatures as per MOP required.)
Please Note :
* To be accompanied by a copy of the gazette notification along with updated PAN Card. If the change of name is on account of marriage,
an attested copy of the marriage certificate along with updated PAN Card must be submitted (Applicable for CASA accounts only).
1. For change in address, please provide proof (self attested) of the new address by submitting a copy of Passport / Driving Licence / Election
Card / Electricity Bill or Landline Telephone Bill, not more than 3 months old (For Demat only) and for CASA as per KYC Grid. Also for change
in address request for a Demat A/c please provide valid identity proof & a copy of latest DP transaction statement along with new address proof.
2. For updating PAN Number, kindly provide an original copy of PAN Card.
3. For change of bank details in case of a Demat account; proof of the new bank details are required to be submitted (attested copy of bank
statement or copy of Cheque)
4. Please submit separate requests for different client IDs (For Demat only)
5. For Demat related requests, the form must be signed by all the account holders (For Individuals) and by Authorized Signatories as registered
(For Non-Individuals).
6. In case of Mutual Fund Investment, submit the "KYC Details Change Form for Individuals / Non Individuals" to KRA (KYC Registration Agency)
for affecting address change and contact details change across all AMC's. Forms are available on respective AMC/KRA sites.
7. In case of Mutual Fund, for any change in mode of operation, change in name, signature & Bank details, customer to give a separate request for
each AMC (folio wise) to the Bank or to the AMC directly. In case of name change on account of marriage Notarized copy of Marriage certificate,
Pan Card with new name and old and new signature of the investor, if so changed, attested by Bank is required.
8. For change in Mobile / E-mail Id, please provide an ID proof.
9. Please note that address change at account level will be done only when you have mentioned the respective account number at the top.
10 For change of bank details in case of a NEFT account; details of new bank details are required to be submitted with (cancelled copy of Cheque).
11. Please note that address change at terminal level will be done only when you have mentioned the respective MID/TID number at the top and
address proof given.

Acknowledgement Slip

Bank Official (Sign and stamp)

For Kotak Mahindra Bank Ltd.,

Kotak Mahindra Bank Ltd. CIN: L65110MH1985PLC03813

Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra (E), Mumbai - 400 051. www.kotak.com