KYC CHANGE / ADDITION & ACCOUNT REACTIVATION REQUEST FORM | INDIVIDUAL | RBL APPENDIX-'A'

Religare Broking Limited PHOTO

Club 125 (Tower A) A-3,4 & 5, Sector- 125, ACKNOWLEDGMENT NO. S241203805
Noida-201301 (U.P.)
Ph.: 0120-4866666 Fax: 0120-4866275
(Please fill this update/modification form in ENGLISH and in BLOCK LETTERS)
(Please tick (symbol of tick) the box on Left margin of appropriate row where CHANGE/CORRECTION is required and provide the details in the corresponding row)
Update my KYC details as per below Re-activate my account and update my KYC details Re-activate my account with no change in KYC
A ACCOUNT DETAILS Trading Account Number _________________
RM2062
signature/thumb across
Digitally signed by

Demat Account No 1 0 8 8 6 1 9 7 C - KYC Number, if available

R Manoharan
Date: 2024.12.03 13:11:43

photograph
+5:30
Reason: Profile Modification
Location: COIMBATORE

B IDENTITY DETAILS Aadhar Number 3 6 5 9 PAN A O P P M 1 0 7 5 G

Name* (Same as ID Proof) _______________________________________________________
MR First
R MANOHARAN Name Middle Name Last Name
Father Spouse Name* ________________________________________________
RAMASWAMY
Gender M-Male F-Female T-Transgender Date of Birth D1D M6 M0Y Y2Y Y1 9 8 1
Marital Status* Married Unmarried Others _____________________________________
Please Specify
Citizenship IN-Indian Others _____________________________________________________
Please Specify
Residential Status Resident Individual Non Resident Indian Foreign National Person of Indian Origin
Specify the proof of Identity Submitted Aadhar Card Any Other (Please Specify) ______________________________________
Please Specify

(Please refer instruction ‘C’ at the end)

C NEW ADDRESS DETAILS ____________________________________________________________________________________
5/52D JAWAHAR STREET RATHINAPURI Rathinapuri Coimbatore North Coimbatore Coimbatore North
1. New Correspondence Address ____________________________________________________________________________________
City/Town/Village C O I M B A T O R E District
State T A M I L N A D U Pin Code 6 4 1 0 2 7 Country I N D I A
Address Type Residential/Business Residential Business Registered Office Unspecified _____________
Please Specify
Specify the proof of Address submitted __________________________________________________ Validity / Expiry
Aadhaar Card D D / MM / Y Y Y Y
2. New Permanent Address ____________________________________________________________________________________
5/52D JAWAHAR STREET RATHINAPURI Rathinapuri Coimbatore North Coimbatore Coimbatore North
(if different from above) ____________________________________________________________________________________
City/Town/Village C O I M B A T O R E District
State T A M I L N A D U Pin Code 6 4 1 0 2 7 Country I N D I A
Address Type Residential/Business Residential Business Registered Office Unspecified _____________
Please Specify
Specify the proof of Address submitted __________________________________________________
Aadhaar Card Validity / Expiry D D / MM / Y Y Y Y
D NEW CONTACT DETAILS
1. Contact Details (Please refer instruction ‘F’ at the end of Form)
Tel (Off.) — Fax —
Tel (Res.) — Mobile 9 1 — 9 9 9 4 3 4 6 7 9 1 SMS Alert Facility* Y N
E-mail ID ____________________________________________________________________________
manosky7@gmail.com Email Alert Facility* Y N
*Stock Exchange(s)/Depositories issue transaction alerts on subscription to SMS / E-mail alert facility directly. *Email & Mobile No. are mandatory in Trading & Depository Account.

E DECLARATION(s)
1. Ownership Declaration - Contact Detail(s)
A. E-mail — I hereby declare that the E-mail ID given by me belongs to me or my family
In case of family, the owner of E-mail ID is my Spouse Dependent children Dependent Parent
B. Mobile — I hereby declare that the Mobile given by me belongs to me or my family
In case of family, the owner of Mobile is my Spouse Dependent children Dependent Parent
2. Declaration for Electronic Communication Yes No
I wish to receive all future communication to me including but not limited to Contract note, Bills and Statement of Account to be sent to the above mentioned ID

I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you of any changes therein,
immediately. In case any of the above information is found to be false or untrue or misleading or misrepresenting, I am aware that I may be held liable for it.
I hereby consent to receiving information from Central KYC Registry through
SMS/Email on the above registered number/email address. Digitally signed by
R Manoharan
Date: 2024.12.03 13:11:43

Place : Coimbatore North

+5:30
Reason: Profile Modification
Location: COIMBATORE

Date : D 3 // M
0 D 2 // 2Y 0Y 2Y 4Y
1 M Sign. of Applicant

SIGNATURE OF ALL ACCOUNT HOLDER(s) FOR OFFICE USE ONLY

KYC Verifier / IPV Details
Name of the person who has done the IPV : .................................................................................................
Digitally signed by
KYC Process Completed by downloading Digi
Designation : .............................................................................. Employee ID: ............................................
R Manoharan
Date: 2024.12.03 13:11:43
+5:30
Locker Data On
Name of Sub Broker/Authorised Person Date 03/12/2024
: .....................................................................................................
Reason: Profile Modification Name of Organization : Religare Broking Limited
Location: COIMBATORE
C-KYC Institution Code : IN0653
Signature of the person who has done the IPV .............................................................................................
Sign. of 1st Holder Sign. of 2nd Holder Sign. of 3rd Holder Originals Verified and Self-Attested Documents Copies received
Coimbatore North
Place : ................................................................. Date D 3 // M
0 D 2 // Y
1 M 2 Y
0 Y
2 Y
4 Place : ................................................................. Date D D / MM / Y Y Y Y
KYC CHANGE / ADDITION REQUEST FORM | INDIVIDUAL | RBL (Mandatory for accounts activated prior to 1st August, 2016) APPENDIX-'B'
APPENDIX-'B'
1. PERSONAL DETAILS
Name* (Same as per KYC Records) Prefix
MR First Name
R MANOHARAN Middle Name
______________________________________________________
Last Name
Maiden Name (If any*) ______________________________________________________
Mother Name* ______________________________________________________
Occupation Type* S-Service ( Private Sector Public Sector Government Sector)
O-Others ( Professional Self Employed Retired Housewife Student)
B-Business Not Categorised _______________________________________________
(Please Specify)

2. PROOF OF IDENTITY (PoI)* (Please refer instruction ‘B’ at the end)

(Certified copy of any one of the following Proof of Identity (PoI) needs to be submitted)
A-Passport Number Passport Expiry Date D D / MM / Y Y Y Y

B-Voter ID Card
C-Driving Licence Driving Licence Expiry Date D D / M M / Y Y Y Y
D-UID (Aadhaar) 3 6 5 9
Z-Others (any document notified by the central government)
Identification Number

3. PROOF OF ADDRESS (POA) (Current / Permanent / Overseas details)

Passport Number Passport Expiry Date D D / MM / Y Y Y Y
Voter ID Card
Driving Licence Driving Licence Expiry Date D D / M M / Y Y Y Y
UID (Aadhaar) 3 6 5 9
Others (any document notified by the central government)
Identification Number

4. INCOME DECLARATION (Please specify gross annual income details) (Financial Document to provided in case client is active derivative Segment.
Income Range Per Annum Below `1Lac `1-5Lac `5-10Lac `10-25Lac `25Lac-1Crore Above `1Crore
OR Net-worth Amount* (`) ...................................................... As on Date : D D / M M / Y Y Y Y (Net worth should not be older than 1 year)
5. FATCA DECLARATION : (Please refer instruction ‘G’ at the end)
(A) I do not have any residence for tax purposes with jurisdiction (Out Side India)
(B) I have the residence for tax purposes with jurisdictions out side India (if opted for ‘B’, please fill additional FATCA Declaration form)

6. DETAILS OF RELATED PERSON (If Opted related person if required to provide his/her KYC)
Addition of Related Person Deletion of Related Person KYC Number of Related Person (If available*)
Related Person Type* Guardian of Minor Authorized Representative
Name* Prefix First Name Middle Name Last Name
(If KYC Number and name are provided, POI details are optional)
PROOF OF IDENTITY (PoI) OF RELATED PERSON* (Please see instruction (H) at the end)
A-Passport Number Passport Expiry Date D D / M M / Y Y Y Y
B-Voter ID Card
C-Driving Licence Expiry Date D D / M M / Y Y Y Y
D-UID (Aadhaar)
Z-Others (any document notified by the central government
Related Person Signature
Identification Number
DECLARATION SIGNATURE OF APPLICANT FOR OFFICE USE ONLY
I hereby declare that the details KYC Verifier / IPV Details
furnished above are true and Name of the person who has done the IPV : .................................................................................
correct to the best of my Signature of 1st Holder
Digitally signed by
R Manoharan
KYC Process Completed by downloading
Designation : ..............................................................
knowledge and belief and I Employee ID: .............................................................
undertake to inform your of any
Date: 2024.12.03 13:11:43
+5:30
Reason: Profile Modification
Digi Locker Data On Date 03/12/2024
Name of Sub Broker/Authorised Person : ......................................................................................
changes therein, immediately. In Location: COIMBATORE Name of Organization : Religare Broking Limited
case any of the above C-KYC Institution Code : IN0653
information is found to be false Signature of the person who has done the IPV ..............................................................................
or untrue or misleading or Originals Verified and Self-Attested Documents Copies received
misrepresenting, I am aware that
I may be held liable for it. Signature of 2nd Holder
I hereby consent to receiving
information from Central KYC
Registry through SMS/Email on
my registered number/email
address.
Signature of 3rd Holder

Date 3 // M
D0 D 2 // Y
1 M 2 Y
0 Y
2 Y
4 Coimbatore North Place : ................................................................. Date
Place : ........................................... D D / MM / Y Y Y Y
KYC CHANGE / ADDITION REQUEST FORM | INDIVIDUAL | RBL

CATEGORIZATION OF THE CLIENT FOR COMMODITY

Category Farmers/FPOs Value Chain Participants (VCPs) Proprietary Traders
(Please Specify) Domestic Financial Institutional investors Foreign Participants Others
Note: If you have select category except ”Other” Please fill the declaration of Commodity.
DECLARATION SIGNATURE OF APPLICANT
I hereby declare that the details furnished above are true and correct to the best of my/our knowledge
and belief and I undertake to inform your of any changes therein, immediately. In case any of the above
information is found to be false or untrue or misleading or misrepresenting, I am/we are aware that I/we Digitally signed by
R Manoharan
may be held liable for it. Date: 2024.12.03 13:11:43
+5:30
Reason: Profile Modification
Location: COIMBATORE

Place : Coimbatore North Date : D 3 // M

0 D 2 // Y
1 M 2 Y Y 4Y
0 2 Signature of all Account Holder(s)

INSTRUCTION / CHECK LIST FOR FILLING KYC FORM

A. IMPORTANT POINTS: Government in consultation with the Regulator.
1. Self attested copy of PAN card is mandatory for all clients, including C. In case of “Officially Valid Documents (OVD)” listed in Proof of Identity &
Promoters / Partners / Karta / Trustees and whole time directors and Address does not contain updated address, the document as prescribed
persons authorised to deal in securities/ commodities derivatives on below shall be deemed to be the OVD for the limited purpose of proof of
behalf of company / firm / others. address for three month under Conditions that welcome letter after KYC
2. Copies of all the documents submitted by the applicant should be self- should not returned back in reasonable time to start transaction in
attested and accompanied by originals for verification. In case the account:
original of any document is not produced for verification, then the copies 1. Utility bill which is not more than two months old of any service provider
should be properly attested by entities authorised for attesting the (electricity, telephone, post-paid mobile phone, piped gas, water bill).
documents, as per the below mentioned list. 2. Property or Municipal tax receipt.
3. If any proof of identity or address is in a foreign language, then 3. Pension or family pension payment orders (PPOs) issued to retired
translation into English is required. employees by Government Departments or Public Sector Undertakings,
4. Name & address of the applicant mentioned on the KYC form, should if they contain the address.
match with the documentary proof submitted. 4. Letter of allotment of accommodation from employer issued by State
5. If current & permanent address are different, then proofs for both have to Government or Central Government Departments, statutory or regulatory
be submitted. bodies, public sector undertakings, scheduled commercial banks,
6. Sole proprietor must make the application in his individual name & financial institutions and listed companies and leave and licence
capacity. agreements with such employers allotting official accommodation.
7. For non-residents and foreign nationals, (allowed to trade subject to RBI 5. For FII / sub account, Power of Attorney given by FII / subaccount to the
and FEMA guidelines), copy of passport / PIO Card / OCI Card and Custodians (which are duly notarized and / or apostiled or consularised)
overseas address proof is mandatory. that gives the registered address should be taken.
8. For foreign entities, CIN is optional; and in the absence of DIN no. for the D. Exemptions / Clarifications to PAN (*Sufficient documentary evidence
directors, their passport copy should be given. in support of such claims to be collected.)
9. In case of Merchant Navy NRI's, Mariner's declaration or certified copy of 1. In case of transactions undertaken on behalf of Central Government and
CDC (Continuous Discharge Certificate) is to be submitted along with / or State Government and by officials appointed by Courts e.g. Official
other statutory approvals required for investment in commodities. (as liquidator, Court receiver etc.
applicable) 2. Investors residing in the state of Sikkim.
10. For opening an account with Depository participant or Mutual Fund, for a 3. UN entities / multilateral agencies exempt from paying taxes / filing tax
minor, photocopy of the School Leaving Certificate / Mark sheet issued returns in India.
by Higher Secondary Board / Passport of Minor / Birth Certificate must be 4. SIP of Mutual Funds upto Rs. 50,000/- p.a.
provided. 5. In case of institutional clients, namely, FIIs, MFs, VCFs, FVCIs,
11. Politically Exposed Persons (PEP) are defined as individuals who are or Scheduled Commercial Banks, Multilateral and Bilateral Development
have been entrusted with prominent public functions in a foreign country, Financial Institutions, State Industrial Development Corporations,
e.g., Heads of States or of Governments, senior politicians, senior Insurance Companies registered with IRDA and Public Financial
Government / judicial / military officers, senior executives of state owned Institution as defined under section 4A of the Companies Act, 1956,
corporations, important political party officials, etc. Custodians shall verify the PAN card details with the original PAN card
B Proof of Identity (POI) & Address (POA): - List of documents and provide duly certified copies of such verified PAN details to the
admissible as Proof of Identity & Address: intermediary.
1. Passport. E. List of people authorised to attest the documents:
2. Driving license. 1. Notary Public, Gazetted Officer, Manager of a Scheduled Commercial /
3. Unique Identification Number (UID) (Aadhaar). Co-operative Bank or Multinational Foreign Banks (Name, Designation &
4. Voter's Identity Card issued by Election Commission of India. Seal should be affixed on the copy).
5. Job card issued by NREGA duly signed by an officer of the State 2. In case of NRIs, authorised officials of overseas branches of Scheduled
Government. Commercial Banks registered in India, Notary Public, Court Magistrate,
Judge, Indian Embassy / Consulate General in the country where the
6. Letter issued by the National Population Register containing details of client resides are permitted to attest the documents.
name, address, or any other document as notified by the Central
 Address Proof

Digitally signed by
R Manoharan
Latitude 11.023724 Date: 2024.12.03 13:11:43
+5:30
Reason: Profile Modification
Location: COIMBATORE
Longitude 76.9830107
 Income Proof

Digitally signed by
R Manoharan
Date: 2024.12.03 13:11:43
+5:30
Reason: Profile Modification
Location: COIMBATORE
 DECLARATION FOR NAME MISMATCH

 I state that I have applied for profile modification in my trading/demat account

with you i.e. Religare Broking Limited (RBL).
 I state that I have submitted my Income Proof &/or Bank account proof &/or
Address proof for my said profile modification, wherein my name is spelt
differently from that mentioned in my trading/ demat account.
 I state that the document/s submitted for profile modification belong to one and
the same person, i.e. myself.
 I agree to indemnify RBL at all times from and against all costs (including
attorney’s fees), charges, damages, penalties suffered &/or incurred by RBL for
any act done or omitted to be done on above declaration.

Client Signature

Digitally signed by
R Manoharan
Date: 2024.12.03 13:11:43
+5:30
Reason: Profile Modification
Location: COIMBATORE
 DigiLocker verified e-Aadhaar
This document is generated from verified Aadhaar XML obtained from DigiLocker with due user consent and authentication

Document type e-Aadhaar generated from DigiLocker verified Aadhaar XML

XML verified

Generation date 2024-12-03T 12:42:56.863+05:30 Download date 2024-12-03T 12:42:56.863+05:30

Masked Aadhaar number

xxxxxxxx3659
Name Manoharan Ramasamy

Date of Birth 16-02-1981

Gender Male

c/o , s/o S/O: Ramasamy

Address 5/52D JAWAHAR STREET RATHINAPURI,

RATHINAPURI COIMBATORE NORTH
COIMBATORE

City Coimbatore North

Pin Code 641027 State Tamil Nadu

Your data has been fetched securely from Digilocker with unique id : 44eda1f293414fc1be4a2b7cfce0feec

Declaration:

I have authorized Religare Broking Limited to download issued/uploaded documents from digilocker and use these as
officially valid document for account opening process.

I provide my consent to Religare Broking Limited for my Name, Date of Birth, and Gender to be used for the purpose of
Digital/Online KYC and for sharing the Aadhaar data and documents with KRA.

The shared documents and data shall be used by KRA to validate the KYC information.

I authorize Religare Broking Limited to pull my e-Aadhaar data.

This digitally signed verification document is valid as per the IT Act 2000 when used electronically.

Digitally signed by
R Manoharan
Date: 2024.12.03 13:11:43
+5:30
Reason: Profile Modification
Location: COIMBATORE