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Income Declaration

The document is an income declaration form required under the Prevention of Money Laundering Act, 2002, and SEBI guidelines. It collects personal information, gross annual income, asset value, and details regarding politically exposed persons. The individual must confirm the source of funds for trading activities and provide a self-attested copy of their PAN card.

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12 views2 pages

Income Declaration

The document is an income declaration form required under the Prevention of Money Laundering Act, 2002, and SEBI guidelines. It collects personal information, gross annual income, asset value, and details regarding politically exposed persons. The individual must confirm the source of funds for trading activities and provide a self-attested copy of their PAN card.

Uploaded by

Only for Youtube
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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INCOME DECLARATION

This information is sought under the Prevention of Money Laundering Act, 2002, the rules notified
there under and SEBI’s guidelines on Anti Money Laundering.

Date:

Consortium Securities Pvt. Ltd.


Consortium Commodities Pvt. Ltd.
36, Sant Nagar, East of Kailash,
New Delhi – 110 065

Ref: Trading account No.: _________________ DP account No.: ________________________

Name of the Individual (In Full)

Permanent Address (If different from as


provided in KYC – Attach proof)

Correspondence Address (If different from as


provided in KYC – Attach proof)

Email ID (If different from as provided in KYC)

Contact Details (If different from as provided in


KYC)
Landline Number
Mobile Number

Gross Annual Income Declaration


a) Below Rs. 1,00,000
b) Rs. 1,00,000 to Rs. 5,00,000
c) Rs. 5,00,000 to Rs. 10,00,000
d) Rs. 10,00,000 to Rs. 25,00,000
e) Above Rs. 25,00,000 (Pls. specify the amount)

Value of Assets (Pls. Specify )

If the following is additionally applicable to you


a) Politically Exposed Person (PEP) YES/ NO
b) Related to a Politically Exposed Person (PEP) YES/ NO
c) Senior government/judicial/military
officers/executives of state owned corporations YES/ NO
or their family member or close relative
d) Current or Former MP/MLA/MLC/Head of
state or of Governments or their family member
or close relative YES/ NO
e) Politician or their family member or close
relative YES/ NO
f) Civil Servant/Bureaucrat or family member or
close relative of Civil Servant/Bureaucrat YES/ NO

I _______________________________, (Name) provide you the following details as per your


requirement. I further request you to kindly update the same in your records as per the above-
mentioned details.

We hereby further confirm/undertake that the investments/trading done in securities market are from
our own/borrowed sources of funds and we confirm that the funds utilized for trading activity by us is in
compliance with the rules, regulations and guidelines stipulated under PMLA.

I _____________________________, (Name) hereby enclose the self attested copy of PAN card No.
_______________________.

Yours faithfully,

Name of the Individual

Signature:

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