Sip Auto Debit Form[1]

Systematic Investment Plan (SIP) Auto Debit Instruction Form Before filling this Instruction Form please ensure you have filled in the SIP Application Form ticking ECS Authorisation in SIP payment details (Section 5)

Broker Code

First Investment with a Current Date Cheque

Sub-Broker Code

Date & Time of Receipts

New Application Cancellation Change in Bank Account*

Application to be submitted at least 30 days before the commencement of SIP

I/We hereby apply to the Trustee of ICICI Prudential Mutual Fund for the Systematic Investment Plan (SIP) Enrolment under the following scheme and agree to abide by the terms and conditions of the plan.

[* Please provide a cancelled cheque]

APPLICANT AND SIP DETAILS Sole / First Applicant’s Name Application No.

Folio No.

Scheme Plan Option & Sub Option Each SIP Amount (Rs.) First SIP Transaction via Cheque No. (Note : Cheque should be drawn on bank, details provided below) Cheque Details SIP Date 1st 7th 10th 15th 25th Cheque No. Date SIP Period From To MM YYYY MM YYYY

Amount

We hereby, authorise ICICI Prudential Mutual Fund and their authorised service providers, to debit my/our following bank account by ECS (Debit Clearing) for collection of SIP payments. PARTICULARS OF BANK ACCOUNT (Mandatory) Bank Account Holders Name Bank Name Branch Name Account Number

Account Type

9 Digit MICR Code

Savings

Current

Cash Credit

(Please enter the 9 digit number that appears in your cheque next to the cheque number. In case of “AT PAR” cheques, investors need to mentioned the MICR number of his actual bank branch.)

I/We hereby declare that the particulars given above are correct and express my willingness to make payments referred above through participation in ECS. If the transaction is delayed or not effected at all for reasons of incomplete or incorrect information, I/We would not hold the user institution responsible. I/We will also inform ICICI Prudential Mutual Fund, about any changes in my bank account. I/We have read and agreed to the terms and conditions mentioned overleaf.

3rd Holder

2nd Holder

1st Holder

Signatures as in Bank Records

✄

✄ Authorisation of the Bank Account Holder

This is to inform I/we have registered for the RBI's Electronic Clearing Service (Debit Clearing) and that my payment towards my investment in ICICI Prudential Mutual Fund shall be made from my/our below mentioned bank account with your bank. I/We authorise the representative carrying this ECS mandate Form to get it verified & executed.

Account Number

3rd Holder

2nd Holder

1st Holder

Signatures as in Bank Records

✄

✄ Acknowledgement Slip (Auto Debit) - ICICI Prudential Mutual Fund

Name of the Applicant ______________________________________________________________ Application/Folio No. ______________________ D D M M Y Y Y Y D D M M Y Y Y Y Each SIP Amount (Rs.) _________________________________________ SIP Period - From SIP Period - To Scheme ____________________________ Plan __________________________ Option & Sub-option ___________________________________

Signature, Date & Stamp

19 30-Mar-07