Annexure A - Request for dormant account activation and
updation of Re-KYC (Resident Individual Customer)
Date : D D / M M / Y Y Y Y Service Request No:
PART A – Dormant Account Activation:
Account Number/s:
Dear Sir / Madam,
I / We, holder/s of above-mentioned Account/s with your Bank, request you to activate my / our Account, which is in
Dormant status. The Reason for no operations in the account: __________________________________________________
I/We confirm enclosing Self-attested copy of Officially Valid Documents (Identity and Address proof) for account holder/s.
I / We hereby confirm that there is no change in the contact details updated in bank records. Please activate the
account basis documents submitted.
OR
I / We hereby request you to update the contact details as mentioned in PART B& activate the account.I understand
that only contact details will be updated however rekyc will not be updated.
OR
I / We hereby request you to update the contact details and / or with Re-KYC as mentioned in PART B and activate
the account.
Customer Name: _________________________________ _____________________________
(Account Holder 1) (Account Holder 2)
Customer Signature/s: _____________________________ _____________________________
(Account Holder 1) (Account Holder 2)
KMBL/Mar-2024/V 1.08
PART B – Re-KYC (updation of KYC information):
Details for Account Holder-1
Section A – Personal:
CRN: Latest photograph
(Mandatory)
Customer Name: F I R S T N A M E M I D D L E N A M E S U R N A M E
Section B – Occupation & Income:
Occupation Salaried Self Employed Student Housewife Politician
Others please specify ______________________
Annual income (Rs.) Name of organization & designation (if salaried) Nature of business activity (if self- employed)
Section C – Address & contact details:
There is no change in my contact details / mailing address. Attached herewith are the KYC documents for the
purpose of Re-KYC updation.
I wish to change my mailing address / contact details in the bank records. Attached herewith are the KYC
documents matching with the new details for the purpose of Re-KYC.
Section D – To be filled ONLY IF THERE IS A CHANGE in the mailing address or contact details:
Please update the following information in your records. I have provided identity / address proof for the same.
For updating New Address (provide Address Proof Document)
Address:
City: Pin-code:
State: Country:
For updating New Mobile Number / Email id (provide Identity Proof Document)
Mobile No.: I S D –
Email ID
Customer's Sign
(in case of change in contact details)
KMBL/Mar-2024/V 1.08
Section E – FATCA / CRS Declaration:
Part A Part B
Yes No
a. Are you citizen of any country other than *Address for Tax Residence
India (dual / multiple [including Green card]
*City
b. Is your Country of birth is any country other *Country Place within the
than India of Birth Country of Birth
(In case Country of Birth is USA, however Nationality and Country of Tax Residency is other than USA, please provide documentary evidence)
c. Are you Tax resident of ANY country / ies
other than India Source of Wealth Nationality
Please List below the details, confirming ALL countries of tax residency/ permanent residency/ citizenship and ALL Tax Identification Numbers.
d. Do you have POA or a man date holder who *Country of Tax identification Tax identification Document
Tax residency Number $ (TIN or functional equivalent)
has an address outside India
e. Is you Address or telephone number outside 'It is mandatory to supply a TIN or functional equivalent (in case TIN not available) if the country in which you are tax resident issues
India such identifiers. if no TIN / functional equivalent is yet available or has not yet been issued, please provide an explanation below:
If your answer to any of the above questions is a 'YES',please fill Part B
I _________________________ being the beneficial owner of the account opened / to be opened with Kotak Mahindra Bank Limited and the income credited therein, declare that the above information and
information in the submitted documents to be true, correct and updated, and the submitted documents are genuine and duly executed.
I acknowledge that towards compliance with tax information sharing laws, such as FATCA / CRS, the Bank may be required to seek additional personal, tax and beneficial owner information and certain
certifications and documentation from the account holder. Such information may be sought either at the time of account opening or any time subsequently. In certain circumstances (including if the Bank does not
receive a valid self-certification from me) the Bank may be obliged to share information on my account with relevant tax authorities. Should there be any change in any information provided by me I ensure that I
will intimate the Bank promptly, i.e., within 30 days.
Towards compliance with such laws, the Bank may also be required to provide information to any institutions such as withholding agents for the purpose of ensuring appropriate withholding from the account or
any proceeds in relation thereto. As may be required by domestic or overseas regulators/ tax authorities, the Bank may also be constrained to withhold and pay out any sums from my account or close or suspend
my account(s).
I also understand that the account will be reported if any one of the aforesaid FATCA / CRS criteria for any of the account holders i.e., primary or joint are met.
I understand that any inaccurate, incomplete or false disclosure of statement of financial transaction or reportable account by me would lead to penal consequence on the Bank under applicable law. The Bank
shall be entitled to take any necessary action and recover from me such amount levied due to such inaccuracy, incompleteness or false disclosure. I shall indemnify the Bank in respect of all or any liabilities incurred
by Bank, by reason of any of the information or particulars given by me, being incorrect or false or being suppressed or omitted.
Details for Account Holder-2
Section A – Personal:
CRN:
Latest photograph
Customer Name: F I R S T N A M E M I D D L E N A M E S U R N A M E (Mandatory)
Section B – Occupation & Income:
Occupation Salaried Self Employed Student Housewife Politician
Others please specify ___________________
Annual income (Rs.) Name of organization & designation (if salaried) Nature of business activity (if self- employed)
Section C – Address & contact details:
There is no change in my contact details/mailing address. Attached herewith are the KYC documents for the purpose
of Re-KYC updation.
I wish to change my mailing address/contact details in the bank records. Attached herewith are the KYC documents
matching with the new details for the purpose of Re-KYC.
Section D – To be filled ONLY IF THERE IS A CHANGE in the mailing address or contact details:
Please update the following information in your records. I have provided identity / address proof for the same.
KMBL/Mar-2024/V 1.08
For updating New Address (provide Address Proof Document)
Address:
City: Pin-code:
State: Country:
For updating New Mobile Number / Email id (provide Identity Proof Document)
Mobile No.: I S D -
Email ID
Customer's Sign
(in case of change in contact details)
Section E – FATCA / CRS Declaration:
Part A Part B
Yes No
a. Are you citizen of any country other than *Address for Tax Residence
India (dual / multiple [including Green card]
*City
b. Is your Country of birth is any country other *Country Place within the
than India of Birth Country of Birth
(In case Country of Birth is USA, however Nationality and Country of Tax Residency is other than USA, please provide documentary evidence)
c. Are you Tax resident of ANY country / ies
other than India Source of Wealth Nationality
Please List below the details, confirming ALL countries of tax residency/ permanent residency/ citizenship and ALL Tax Identification Numbers.
d. Do you have POA or a man date holder who *Country of Tax identification Tax identification Document
Tax residency Number $ (TIN or functional equivalent)
has an address outside India
e. Is you Address or telephone number outside 'It is mandatory to supply a TIN or functional equivalent (in case TIN not available) if the country in which you are tax resident issues
India such identifiers. if no TIN / functional equivalent is yet available or has not yet been issued, please provide an explanation below:
If your answer to any of the above questions is a 'YES',please fill Part B
I _________________________ being the beneficial owner of the account opened / to be opened with Kotak Mahindra Bank Limited and the income credited therein, declare that the above information and
information in the submitted documents to be true, correct and updated, and the submitted documents are genuine and duly executed.
I acknowledge that towards compliance with tax information sharing laws, such as FATCA / CRS, the Bank may be required to seek additional personal, tax and beneficial owner information and certain
certifications and documentation from the account holder. Such information may be sought either at the time of account opening or any time subsequently. In certain circumstances (including if the Bank does not
receive a valid self-certification from me) the Bank may be obliged to share information on my account with relevant tax authorities. Should there be any change in any information provided by me I ensure that I
will intimate the Bank promptly, i.e., within 30 days.
Towards compliance with such laws, the Bank may also be required to provide information to any institutions such as withholding agents for the purpose of ensuring appropriate withholding from the account or
any proceeds in relation thereto. As may be required by domestic or overseas regulators/ tax authorities, the Bank may also be constrained to withhold and pay out any sums from my account or close or suspend
my account(s).
I also understand that the account will be reported if any one of the aforesaid FATCA / CRS criteria for any of the account holders i.e., primary or joint are met.
I understand that any inaccurate, incomplete or false disclosure of statement of financial transaction or reportable account by me would lead to penal consequence on the Bank under applicable law. The Bank
shall be entitled to take any necessary action and recover from me such amount levied due to such inaccuracy, incompleteness or false disclosure. I shall indemnify the Bank in respect of all or any liabilities incurred
by Bank, by reason of any of the information or particulars given by me, being incorrect or false or being suppressed or omitted.
I / We, do hereby solemnly declare, that the information provided above with respect to my / our account is true, correct
and complete and the said details may be updated in the Bank records.
Signature of the First Holder Signature of the Second Holder
Name: Name:
*Note: In case of more than 2 holders, please attach additional form.
Customer Acknowledgement Copy: (Applicable if submitted at the branch)
Service Request No: Acknowledgement date: D D / M M / Y Y Y Y
Signature of the Bank Official:
KMBL/Mar-2024/V 1.08
