Instructions / Checklist For Filling KYC Form

Instructions / checklist for filling KYC form
A. Important points
1. Self attested copy of PAN card is mandatory for all clients, including Promoters /Partners /Karta /Trustees and whole time directors and persons authorized to deal in securities
on behalf of company/firm/others.
2. Copies of all the documents submitted by the applicant should be self-attested and accompanied by originals for verification. In case the original of any document is not
produced for verification, then the copies should be properly attested by entities authorized for attesting the documents, as per the below mentioned list.
3. If any proof of identity or address is in a foreign language, then translation into English is required.
4. Name & address of the applicant mentioned on the KYC form, should match with the documentary proof submitted.
5. If correspondence & permanent address are different, then proofs for both have to be submitted.
6. Sole proprietor must make the application in his individual name & capacity.
7. For non-residents and foreign nationals, (allowed to trade subject to RBI and FEMA guidelines), copy of passport/PIO Card/OCI Card and overseas address proof is mandatory.
8. For foreign entities, CIN is optional; and in the absence of DIN no. for the directors, their passport copy should be given.
9. In case of Merchant Navy NRI's, Mariner's declaration or certified copy of CDC (Continuous Discharge Certificate) is to be submitted along with other statutory approvals
required for investment in commodities.
10. Politically Exposed Persons (PEP) are defined as individuals who are or have been entrusted with prominent public functions in a foreign country, e.g., Heads of States or of
Governments, senior politicians, senior Government/judicial/ military officers, senior executives of state owned corporations, important political party officials, etc.
B. Proof of Identity (POI)

List of documents admissible as Proof of Identity:
1. Unique Identification Number (UID) (Aadhaar)/ Passport/ Voter ID card/ Driving license.
2. PAN card with photograph.
3. Identity card / document with applicant's Photo, issued by any of the following: Central/State Government and its Departments, Statutory/ Regulatory Authorities, Public Sector
Undertakings, Scheduled Commercial Banks, Public Financial Institutions, Colleges affiliated to Universities, Professional Bodies such as ICAI, ICWAI, ICSI, Bar Council etc., to
their Members; and Credit cards/Debit cards issued by Banks.
C. Proof of Address (POA)

List of documents admissible as Proof of Address: (*Documents having an expiry date should be valid on the date of submission.)
1. Passport/ Voters Identity Card/ Ration Card/ Registered Lease or Sale Agreement of Residence/ Driving License/ Flat Maintenance bill/ Insurance Copy.
2. Utility bills like Telephone Bill (only land line), Electricity bill or Gas bill - Not more than 3 months old.
3. Bank Account Statement/Passbook - Not more than 3 months old.
4. Self-declaration by High Court and Supreme Court judges, giving the new address in respect of their own accounts.
5. Proof of address issued by any of the following: Bank Managers of Scheduled Commercial Banks / Scheduled Co-Operative Bank / Multinational Foreign Banks / Gazetted
Officer / Notary Public / Elected representatives to the Legislative Assembly/ Parliament / Documents issued by any Govt. or Statutory Authority.
6. Identity card/document with address, issued by any of the following: Central/State Government and its departments, Statutory / Regulatory Authorities, Public Sector
Undertakings, Scheduled Commercial Banks, Public Financial Institutions, Colleges affiliated to Universities and Professional Bodies such as ICAI, ICWAI, ICSI, Bar Council etc.,
to their Members.
7. The proof of address in the name of the spouse may be accepted.
D. Exemptions/clarifications to PAN (*Sufficient documentary evidence in support of such claims to be collected.)

1. In case of transactions undertaken on behalf of Central Government and /or State Government and by officials appointed by Courts e.g. Official liquidator, Court receiver etc.
2. Investors residing in the state of Sikkim (subject to the continued exemption granted by the Government).
E. List of people authorized to attest the documents

1. Notary Public, Gazetted Officer, Manager of a Scheduled Commercial / Co-operative Bank or Multinational Foreign Banks (Name, Designation & Seal should be affixed on the
copy).
2. In case of NRIs, authorized officials of overseas branches of Scheduled Commercial Banks registered in India, Notary Public, Court Magistrate, Judge, Indian Embassy
/Consulate General in the country where the client resides are permitted to attest the documents.
F. In case of non-individuals, additional documents are to be collected from the non-individual entity, over and above the POI and POA, as mentioned below.
Type of entity Documents required
Corporate Copy of balance sheets for the last 2 financial years (to be submitted every year) | Copy of latest share holding pattern, including list of
all those holding control, either directly or indirectly, in the company in terms of SEBI takeover regulations, duly certified by the company
secretary/whole time director/MD (to be submitted every year) | Photograph, POI, POA, PAN and DIN numbers of whole time directors/
two directors in charge of day to day operations | Photograph, POI, POA & PAN of individual promoters holding control either directly or
indirectly | Copies of Memorandum and Articles of Association and Certificate of Incorporation | Copy of Board Resolution for the
investment in commodity market | Copy of Board Resolution or declaration (on letterhead) naming the persons authorised to deal in the
commodity derivatives on behalf of the company.
Partnership firm Copy of balance sheets for the last 2 financial years (to be submitted every year) | Copy of registration/partnership deed. | Authorised
signatories list with specimen signatures | Photograph and copies of POI, POA & PAN of the partners.
Trust Copy of balance sheets for the last 2 financial years (to be submitted every year) | Copy of registration/trust deed. | List of trustees
certified by managing trustees/CA| Photograph and copies of POI, POA & PAN of the trustees.
HUF PAN of HUF | Deed of declaration of HUF & list of copartners | Bank statement/pass-book of HUF | Photograph, POI, POA & PAN of Karta
Government bodies Self certification on letterhead | Authorised signatories list with specimen signatures
Registered society Copy of Registration Certificate under Societies Registration Act | List of Managing Committee Members | Committee resolution for
persons authorised to act as authorised signatories with specimen signatures | True copy of society rules and bye laws certified by the
Chairman/Secretary
G. Copy of cancelled cheque leaf/ pass book/bank statement specifying name of the constituent, MICR Code or/ and IFSC Code of the bank should be submitted.
H. Proof of income: A recent month salary slip/6-month bank statement/demat holding statement
I. Demat master or recent holding statement issued by DP bearing name of the client.
For Individuals:
a. Stock broker has an option of doing 'in-person' verification through web camera at the branch office of the stock broker/sub-broker's office.
For non-individuals:
a. Form need to be initialized by all the authorized signatories.
b. Copy of Board Resolution or declaration (on the letterhead) naming the persons authorized to deal in securities on behalf of company/others & their specimen signatures.
1 Sign wherever you see

S. No. Name of the Document Brief Significance of the Document Page No.
MANDATORY DOCUMENTS AS PRESCRIBED BY SEBI & EXCHANGES
A. KYC form - Document captures the basic information about

1 Account Opening Form 3
the constituent and an instruction/checklist.
2 Tariff Sheet Document detailing the rate/amount of brokerage and other charges 7
levied on the client for trading on the commodity exchange(s).
Rights and Obligations of Document stating the Rights & Obligations of stock broker /trading
3 Members, Authorized member and client for trading on exchanges (including additional rights Annexure
Persons and Clients & obligations in case of internet/wireless technology based trading).
Uniform Risk Disclosure Document detailing risks associated with dealing in the commodity
4 Document (RDD) Annexure
market.
Do’s and Don’ts for the Document detailing do’s and dont’s for trading on exchange for
5 Annexure
Investors education of investors
6 Policies and Procedures Document describing significant policies and procedures of the Broker. Annexure
VOLUNTARY AND OPTIONAL DOCUMENTS AS PROVIDED BY THE STOCK BROKER
7 Annexure - N Disclosure information 8
8 Annexure - O Receipt of KYC, RDD, Rights & Obligations and Do’s and Don’t’s 8
9 Annexure - Q Letter of authority 9
10 Annexure - P Additional Rights & Obligations Annexure

Annexure
11 Nomination Details Collects details of any nomination made for the account 1A
Membership Details
Name of the Trading Member : Zerodha Commodities Private Limited
Exchange registration number : MCX - 46025 | NCDEX - 1138
SEBI Registration number : INZ000038238
Registered Office
153/154, 4th Cross, Dollars Colony, 4th Phase, JP Nagar, Opp. Clarence Public School, Bangalore - 560078.
Ph : 080-47181888
Correspondence Address: Same as above
Compliance Officer : Venu Madhav, Phone No. & Email ID: 080-47181888, compliance@zerodha.com
CEO : Nithin Kamath, Phone No. & Email ID: 080-47181888, ceo@zerodha.com
For any grievance please contact Zerodha at the above address or email complaints@zerodha.com &
Phone no. 91-8047181888.
For any grievance/dispute please contact Zerodha at the above address, email ID or phone number.
In case not satisfied with the response, please contact the concerned exchange at:
1.MCX at grievance@mcxindia.com or Phone No.: 022-67318888
2.NCDEX at askus@ncdex.com or Phone No.: 022-66406084.

Know Your Client (KYC) Application Form - for Individuals
Please fill this form in English and BLOCK Letters
(Please tick the box on the left margin of the appropriate row where CHANGE/CORRECTION is required and provide the details in the corresponding window)
For office use only (To be filled by the financial institution)

Application Type* New Update KYC Number
Account Type* Normal Simplified (for low risk customers) Small
A. Identity details
Photograph
1. Name (Same as ID Proof) Please affix your
recent passport size
1a. Maiden Name (If any) photograph and
2. Father's/Spouse's Name sign across it
2a. Mother's Name Signed by: Dhriti Mohan Mitra
eSigned using Aadhaar (digio.in)
Date: 2021-03-18 13:46:06 IST
F1
3a. Gender Male Female Transgender 3b. Marital Status Single Married Other 3c. DOB
4a. Citizenship Indian Other ___________________(ISO 3166 Country Code )
4b. Residential Status Resident Individual Non Resident Indian Person of Indian Origin Foreign National
Tick if applicable Residence for tax purposes in jurisdiction(s) outside India

ISO 3166 Country Code of Jurisdiction of residence Place of birth_____________________________________
Tax Identification Number or Equivalent ISO3166 Country Code of Birth
5a. PAN
5b. Unique Identification Number (UID) / AADHAR, if any
6. Proof of Identity Submitted Pan Card Other (Please Specify) ____________________________________
B. Contact Details
Telephone (Office) Mobile No
Telephone (Residence) Email ID
C. Address details Address Type: Residential Business Unspecified
2. Residence/Correspondence Address 2021-03-18
Address KRA VERIFIED

PAN: AOGPM8671P
City/Town District Pin Code
State/U.T Code DHRITIMOHAN MITRA Country/ISO Code
Specify the Proof of Address Submitted for Residence / Correspondence Address
Mother's Name
Bijali Mitra
D. DECLARATION
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
Signed by: Dhriti Mohan Mitra
false or untrue or misleading or misrepresenting, I am aware that I may be held liable for it. eSigned using Aadhaar
I hereby consent to receiving information from Central KYC Registry through SMS/Email on the above registered F2
(digio.in) Client Signature
Date: 2021-03-18 13:46:06 IST
number/email address
Place : Date :
FOR OFFICE USE ONLY

In Person Verification (IPV) Details:
Name of the Person who has done the IPV: __________________________________________________
Designation: ____________________________________ Employee ID: __________________________
Name of the Organization: Zerodha Commodities Pvt. Ltd.
Date of the IPV: Signature of the Person who has done the IPV Seal/Stamp of the Intermediary
Originals Verified and Self-Attested Document Copies Received
Date Signature of the Authorized Signatory

3. Permanent Address
Address

State/U.T Code Country/ISO Code
4. Address in the jurisdiction details where applicant is resident outside India for tax purpose (if applicable)
Address

State/U.T Code Country/ISO Code
E. Details of related person (In case of additional related persons, please fill below details)
Addition of Related Person Deletion of Related Person
KYC Number of Related Person (if available)
Related Person Type Guardian of Minor Assignee Authorized Representative
Name
(If KYC number & name are provided, below details are optional)
Proof Of Identity Of Related Person
Identity Proof Submitted Number
Expiry Date :
Others (any document notified by the central govt.) Identification No
Simplified Measures Account-Document Type Code Identification No
F. Bank account details

Account Type: Savings * Current Other
Bank Name ICICI BANK LTD
Branch Address AGARTALA BRANCH
AGARTALA TRIPURA
Account Number 047101509584
MICR Number 799229002 IFSC Code ICIC0000471
G. Other details
Gross Annual Income Details (please specify): Income Range per annum
Below Rs 1 Lakh 1-5 Lakh * 5-10 Lakh 10-25 Lakh >25 Lacs
Or Net-worth as on ________________date___________________ (Net worth should not be older than 1year)
Occupation
Private Sector * Public Sector Government Service Business Professional Agriculturist Retired
Housewife Student Self Employed Others (please specify) ____________________________________
Please tick, as applicable: Politically Exposed Person (PEP) Related to a Politically Exposed Person (PEP)
Not a Politically Exposed Person * Not related to a Politically Exposed Person
Mode in which you wish to receive the RDD, Rights & Obligations, and Guidance Note: Physical Electronic *
H. Past actions
Details of any action/proceedings initiated/pending/ taken by FMC/SEBI/stock exchange(s)/commodity exchange(s)/any other
authority against the applicant/constituent or its partners, promoters/whole time directors/authorized persons in charge of
dealing in securities during the last 3 years________________________________________________________________

I. Depository account(s) details
Depository Name: NSDL CDSL
Depository Participant Name
Beneficiary Name
Depository ID Beneficiary ID
Note : Provide a copy of demat master report or a recent holding statement issued by DP bearing name of the client.
J. Dealings through other members

Whether dealing with any other stock broker/sub-broker (in case dealing with multiple members, provide details of all in a
separate sheet containing all the information as mentioned below)
Name of Member/AP Exchange(s)
Website Exchange registration number
Client code Exchange registration number
Registered office address
Name of Member with whom AP is registered
Details of disputes/dues pending from/to such stock broker
K. Introducer details (optional)

Name of the Introducer
Status of the Introducer - Sub-broker/Remisier/Authorized Person/Existing Client
Address of the Introducer
Phone Number Signature (optional)
L. Trading preferences / experience

No Prior Experience
Years in Commodities 5-10 Years in other Investment Related Field
Please sign in the relevant boxes where you wish to trade. The segment not chosen should be struck off by the client.
Name of Exchange Date of consent Signature
MCX Signed by: Dhriti Mohan Mitra

eSigned using Aadhaar (digio.in) Client Signature F3 (a)
Date: 2021-03-18 13:46:06 IST
If, in future, the client wants to trade on any new segment, a separate authorization/letter should be taken from the client by
the broker.
M. Additional details
(I) Whether you wish to receive communication, including contract note from member in electronic Yes * No
DHRITIMOHANMITRA@GMAIL.COM
form on your email ID. If yes, specify email ID: _______________________________________
N. Sales tax registration details (As applicable)

Name of state Registration number Expiry date
State
Registration number
Central
Expiry date
O. VAT details (As applicable)
Name of state Registration number Expiry date
P. Nomination details (Please tick the appropriate options)

I / We do wish to nominate (Fill the Annexure 1A)
* I / We do not wish to nominate

Declaration
1. I/We hereby declare that the details furnished above are true and correct to the best of my/our knowledge and belief and I/we
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/we are aware that I/we may be held liable for it.
2. I/We confirm having read/been explained and understood the contents of the tariff sheet and all voluntary/non-mandatory
documents.
3. I/We further confirm having read and understood the contents of the 'Rights and Obligations' document(s), 'Risk Disclosure
Document' and 'Dos and Don’ts'. I/We do hereby agree to be bound by such provisions as outlined in these documents. I/We have
also been informed that the standard set of documents has been displayed for Information on Member's designated website,if any.
Date 2021-03-18
eSigned using Aadhaar
Place : South Tripura F4
Date: 2021-03-18 13:46:06 IST
For office use only
UCC Code allotted to the Client _________________________________________________________________________

JN6214
Documents verified with Originals Client Interviewed By In-Person Verification done by

Name of the Employee PRABHAKAR PRABHAKAR
Employee Code Z1626 Z1626
Designation of employee Account Opening Account Opening

Date 2021-03-18 2021-03-18
Signature
I / We undertake that we have made the client aware of 'Policy and Procedures', tariff sheet and all the non-mandatory
documents. I/We have also made the client aware of 'Rights and Obligations' document (s), RDD and Guidance Note. I/We have
given/sent him a copy of all the KYC documents. I/We undertake that any change in the 'Policy and Procedures', tariff sheet and all
the non-mandatory documents would be duly intimated to the clients. I/We also undertake that any change in the 'Rights
and Obligations' and RDD would be made available on my/our website, if any, for the information of the clients.
Signature of the Authorised Signatory
Date : 2021-03-18 Seal/Stamp of the stock broker

Tariff sheet
To
Zerodha Commodities Private Limited
153/154, 4th Cross, 4th Phase, JP Nagar, Dollars Colony, Opp. Clarence School, Bangalore - 560078
Charges for Zerodha trading services
I/ We agree to pay the charges as per following charges structure for our trading account with Zerodha effective from the time
of account opening.
Client ID: JN6214
_______________________
Charge Head Brokerage/Charges
Commodity futures 0.03% of turnover or Rs. 20 per executed order, whichever is lower
Commodity options 0.03% of turnover or Rs. 20 per executed order, whichever is lower
Call & Trade Services Rs. 50 per order placed through a Dealer at Zerodha
Clients who opt to receive physical contract notes will be charged Rs. 20 per contract note plus courier charges at actual.
In addition to the brokerage charge the following charges will also be levied.
Schedule of Charges
Charge Head Charges
Turnover Charges Non-Agri: 0.0036% | Agri: 0.00275%
Commodity Transaction Tax 0.01% on sell side (Non-Agri)
GST 18% on (brokerage + transaction charges)
SEBI Turnover Fees INR 20/crore
Stamp Duty State-wise stamp duty as applicable will be levied
Note : Brokerage will not exceed the rates specified by SEBI and the Exchanges. All Statutory and Regulatory charges will be
levied at actuals. Brokerage is also charged on expired, exercised, and assigned Options contracts.
Turnover for Options is calculated as (Strike + Premium)*Lot Size
Detailed explanation of the Schedule of Charges is available online at :
https://zerodha.com/charge-list

(digio.in)
Date: 2021-03-18 13:46:06 IST
Date D 2021-03-18
D M M Y Y Y Y F5 Client Signature

Disclosure Information Annexure - N
Dear Sir/Madam,
This is to inform you as per Rules, Regulations and Bye-laws of Multi Commodity Exchange of India Ltd. (MCX) that we
do client based trading and Pro-account trading and we are not indulged in portfolio management services.
Regards,
I/We acknowledge receipt of information given above by Zerodha Commodities Private Limited that they do client
base trading and Pro-account trading and they are not indulged in portfolio management services.

F6
Date: 2021-03-18 13:46:06 IST
To Annexure - O
153/154, 4th Cross, Dollars Colony, 4th Phase, JP Nagar, Opp. Clarence Public School, Bangalore - 560078.
Sub: Acknowledgement
This is to acknowledge the receipt of following documents. I further state and confirm that I have read and understood
all the clauses of aforesaid documents.
Sl. No Document
1 Duly Executed Copy of KYC
2 Rights and Obligations
3 Risk Disclosure Document (RDD)
4 Guidance Note - Do's and Dont's for trading on the Exchange(s) for investors
5 Policies and Procedures
6 Additional Rights & Obligations
I also confirm that I have received the relevant clarifications, if any, wherever required from the officials of Zerodha Commodities
Pvt. Ltd.

F7
Date: 2021-03-18 13:46:06 IST

Letter of Authority (Voluntary) Annexure - Q

#153/154, 4th Cross Dollars Colony, Opp. Clarence Public School,
J.P Nagar 4th Phase, Bangalore - 560078
Dear Sir,
I am/We are dealing in commodities with you and in order to facilitate ease of operations, I/we authorize you as under:
1. Authorization for Payment of Depository Participant Charges: I am having depository account with Zerodha Commodities
Pvt Ltd. I request you to debit my trading Account against the demand raised by the depository division of Zerodha
Commodities Pvt Ltd. towards my Depository Charges. I also agree to maintain the adequate balance in my trading account /
pay adequate advance fee for the said reason.
2. Authorization to Retain Credit Balance: I / We request you to retain credit balance in any of my / our account and to use the
idle funds towards our margin/future obligations at the Exchanges unless I/ we instruct you otherwise.
3. Authorization for Communication of Financial Products: I/We have opened an account with you and am/are interested in
knowing about other financial products. I/We authorize you, your group companies and associates to keep me/us informed
with any financial product which Zerodha Commodities Private Limited, its group companies and associates presently issue,
deal in, or distribute or may, from time to time, launch, issue, deal in or distribute; through E-mail, SMS,telephone, print
media or otherwise. This is without legal obligation on you, your group companies and associates to so inform and you or
they may, in their discretion, discontinue sending such information.
4. Running Account Authorization: I/We am /are desirous of regularly dealing in commodity market on Commodity Exchanges
and request you to maintain a running account for funds and commodities on/our behalf without settling the account on
settlement of each transaction on my/our behalf. I/We further request you to retain all amounts payable and commodities
receivable by me/us until specifically requested by me/us in writing to be settled or to be dealt with in any other manner. I/We
understand and agree that no interest will be payable to me/us on the amounts or commodities so retained with you pending
periodical settlement.This running account authorization would continue until it is revoked by me.
I/We request you to settle my fund and securities account (Choose one Option)
Once in a calendar Month
* Once in every calendar Quarter
except the funds given towards collaterals/margin in form of Bank Guarantee and/or Fixed Deposit Receipt
All accounts with credit balances of Rs. 50000/- or lesser may be automatically retained and transfer of funds to the bank
account may not be made as per SEBI circular MIRSD/SE/Cir-19/2009 & Exchange Circular Nos.MCX/INSP/325/2016 &
NCDEX/COMPLIANCE-015/2016/238. I/We confirm you that I will bring to your notice any dispute arising from the statement
of account or settlement so made in writing within 7 working days from the date of receipt of funds/securities or statement of
account or statement related to it, as the case may be at your registered office.
5. I understand that in case my account is in debit balance @0.05% and/or if I have insufficient funds to manage my trading
positions, I will be charged interest as delayed payment charges. I confirm having read the rules & regulation pertaining to
the levy of such interest under the policies & procedures page on Zerodha's website.
6. Authorization for not Providing Confirmation Slips: I/We authorize you not to provide me/us Order Confirmation
/Modification/Cancellation Slips and Trade Confirmation Slips to avoid unnecessary paper work. I/We shall get the required
details from contract notes issued by you.
7. Authorization for Providing Financial Ledger in Digital Form: I/we hereby authorize you to send me/us the financial ledger in
the digital form in the prescribed formed at my/our E-mail ID/Address.
Date 2021-03-18
Place : South Tripura eSigned using Aadhaar
Date:F8
2021-03-18 13:46:06 IST

Page 1 of 5
MHW1/181D/1-1/WBF-M/03-12
047101509584??DHRI0907 799155
MR.DHRITIMOHAN MITRA Your Base Branch: CHITRAKATHA COMPLEX,BELOW

HOTEL SOMRAJ ,,HGB ROAD,799001
VILL NAYAPALLI PO SARASHIMA BELONIA SOUTH
TRIPURA NEAR SATMURA BAZAR
BELONIYA Visit www.icicibank.com
TRIPURA - INDIA - 799155 Dial your Bank 033-33667777
Date: 2021-03-18 13:46:06 IST
Did you know? It's mandatory to be KYC compliant as per RBI guidelines. If you have not submitted your KYC documents, please visit the nearest
branch or contact your Relationship Manager to complete KYC details for your Account.
Summary of Accounts held under Cust ID: 521839825 as on March 18, 2021
ACCOUNT DETAILS - INR
ACCOUNT TYPE A/c BALANCE(I) FIXED DEPOSITS (LINKED) BAL.(II) TOTAL BALANCE(I+II) NOMINATION
Savings A/c 047101509584 50,756.20 0.00 50,756.20 Registered
TOTAL 50,756.20 0.00 50,756.20
Statement of Transactions in Savings Account Number: 047101509584 in INR for the period September 01, 2020 - March 18, 2021
DATE MODE** PARTICULARS DEPOSITS WITHDRAWALS BALANCE
01-09-2020 B/F 182.13
MMT/IMPS/024513166547/Yes/DHRITIMOHA/HDFC
01-09-2020 MOBILE BANKING Bank 5,000.00 5,182.13
BIL/ONL/002064328588/SOUTH
01-09-2020 ASIA/500100666321_SO/Yes 1,000.00 4,182.13
BIL/ONL/002065731646/Reliance
02-09-2020 R/202009021267437/Yes 149.00 4,033.13
MMT/IMPS/024821543579/Dhriti/SUBHASH
04-09-2020 MOBILE BANKING CH/United Bank Of 5,000.00 9,033.13
08-09-2020 OTHER ATMS NFS/TR02601U/CASH WDL/08-09-20 1,500.00 7,533.13
BIL/002074621312/ICRIB0000100637/ICRIB0000100
14-09-2020 NET BANKING 637 35.00 7,498.13
15-09-2020 R/202009151151630/Yes 149.00 7,349.13
19-09-2020 OTHER ATMS NFS/00216017/CASH WDL/19-09-20 1,500.00 5,849.13
24-09-2020 R/202009241161549/Yes 149.00 5,700.13
24-09-2020 R/202009241862737/Yes 10.00 5,690.13
28-09-2020 UPI/027108452565/UPI/euronetgpay.pay/ICICI Bank 399.00 5,291.13
29-09-2020 047101509584:Int.Pd:29-06-2020 to 28-09-2020 29.00 5,320.13
MMT/IMPS/027511188448/yes/DHRITIMOHA/HDFC
01-10-2020 ASIA/500105980467_SO/Yes 21,000.00 5,320.13
05-10-2020 OTHER ATMS NFS/TR02601U/CASH WDL/05-10-20 4,500.00 820.13
12-10-2020 OTHER ATMS NFS/00216015/CASH WDL/10-10-20 2,000.00 320.13
BIL/002097979332/ICRIB0000100637/ICRIB0000100
14-10-2020 NET BANKING 637 35.00 285.13
BIL/002097979332/IPRU LIFE INSURANCE
14-10-2020 COMPANYLIMITEDGTPRIB 35.00 250.13
UPI/028821170477/JIO20BR0005BM23/jio@yesban
14-10-2020 k/Yes Bank Ltd/ 51.00 199.13
19-10-2020 BIL/REV PMT ID 2097979332 35.00 234.13
Page 2 of 5
MR.DHRITIMOHAN MITRA

19-10-2020 BIL/REV PMT ID 2097979332 35.00 269.13
NEFT-N296201283067036-SOUTH ASIAN STOCKS
22-10-2020 LIMITED-DM151 274-00030340037242- 3,000.00 3,269.13
HDFC0000240
22-10-2020 OTHER ATMS NFS/TR0D333U/CASH WDL/22-10-20 2,000.00 1,269.13
BIL/ONL/002105798526/Reliance eSigned using Aadhaar (digio.in)
26-10-2020 R/202010251226769
Date: 2021-03-1821.00
13:46:06 IST 11,248.13
02-11-2020 R/202011021237179/Yes 21.00 11,227.13
BIL/ONL/002119794337/TATA
11-11-2020 SKY/TATASKY_VICI945/Yes 176.00 10,051.13
16-11-2020 R/202011141264833/Yes 199.00 9,852.13
19-11-2020 ASIA/11000002902187_/Yes 3,000.00 5,352.13
23-11-2020 IN303028XX68499_BIU_DHRITIMOHA 826.00 4,127.13
24-11-2020 R/202011241284202/Yes 51.00 4,076.13
27-11-2020 UPI/033219305964/UPI/billdesk.prepai/ICICI Bank 95.00 3,981.13
07-12-2020 OTHER ATMS NFS/VA282601/CASH WDL/07-12-20 2,000.00 14,481.13
14-12-2020 R/202012121314260/Yes 199.00 14,282.13
VPS/GOMOTI
14-12-2020 DEBIT CARD MOTO/202012131935/034814189033/TRIPURA 5,000.00 9,282.13
VPS/AMWAY
14-12-2020 DEBIT CARD INDIA/202012141604/034910044005/AGARTALA 444.00 8,838.13
MMT/IMPS/034923056489/yes/GIOTTUS/UTIB0CCH
14-12-2020 MOBILE BANKING 274 20,000.00 9,662.13
15-12-2020 ASIA/11000004116667_/Yes 2,500.00 7,162.13
16-12-2020 ASIA/11000004203491_/Yes 2,000.00 5,162.13
17-12-2020 ASIA/11000004244281_/Yes 1,000.00 4,162.13
17-12-2020 ASIA/11000004245906_/Yes 3,000.00 1,162.13
28-12-2020 R/202012251482305/Yes 149.00 1,013.13
29-12-2020 NET BANKING INF/INFT/023319449711/643383 /ICICI BANK N 18,000.00 19,013.13
30-12-2020 047101509584:Int.Pd:29-09-2020 to 29-12-2020 50.00 19,063.13
02-01-2021 LIMITED-DM151 141-00030340037242- 16,227.01 35,290.14
HDFC0000240
04-01-2021 ASIA/11000005167885_/Yes 6,000.00 29,290.14
05-01-2021 ASIA/11000005253560_/Yes 5,000.00 24,290.14
05-01-2021 BANK CHARGES ATMDEC CHG/25-12-2020/4179+GST 29.50 24,260.64
08-01-2021 R/202101081369242/Yes 555.00 21,205.64
Page 3 of 5

15-01-2021 R/202101151386080/Yes 51.00 19,978.64
18-01-2021 OTHER ATMS NFS/00216015/CASH WDL/18-01-21 1,500.00
Signed by: Dhriti Mohan Mitra 18,079.64
20-01-2021 NET BANKING INF/INFT/023444954511/700006 /ICICI BANK N 50,000.00 Date: 2021-03-18 13:46:06 IST 68,079.64
28-01-2021 ASIA/11000006550522_/Yes 10,000.00 55,378.64
03-02-2021 ASIA/11000006936492_/Yes 4,000.00 95,228.64
BIL/ONL/000038798369/GEEKGARDEN/GYGUUBLN
06-02-2021 86VUVA/Yes 160.00 95,068.64
09-02-2021 ASIA/11000007479744_/Yes 5,000.00 90,068.64
UPI/104014251843/Bakewalacom/razorpay@icici/ICI
09-02-2021 CIBank/ 253.00 89,815.64
UPI/104113418048/Razorpay
10-02-2021 Refund/razorpay@icici/ICICI Bank 253.00 90,068.64
17-02-2021 ASIA/11000008384629_/Yes 2,000.00 85,392.64
17-02-2021 ASIA/11000008391121_/Yes 6,000.00 79,392.64
BIL/ONL/000049094662/Tripura
20-02-2021 St/TSECL_VICI97663/Yes 911.90 75,980.74
01-03-2021 R/202102281494778/Yes 11.00 75,769.74
01-03-2021 ASIA/11000010098561_/Yes 4,000.00 71,769.74
UPI/106311040674/UPI/gourabsarkar182/State Bank
04-03-2021 Of I 1.00 71,770.74
04-03-2021 ASIA/11000010625701_/Yes 5,000.00 66,770.74
04-03-2021 ASIA/11000010629367_/Yes 10,000.00 56,770.74
04-03-2021 ASIA/11000010632363_/Yes 10,000.00 46,770.74
05-03-2021 ASIA/11000010774033_/Yes 5,000.00 41,770.74
05-03-2021 ASIA/11000010810164_/Yes 10,000.00 31,770.74
BIL/ONL/000066503218/Life
12-03-2021 Insur/LIC_VICI9825701/Yes 3,305.74 27,465.00
15-03-2021 R/202103131528331/Yes 21.00 27,268.00
UPI/107411200981/UPI/angelnse@hdfcba/HDFC
15-03-2021 BANK LTD 11,000.00 15,889.00
Page 4 of 5

UPI/107411549654/Rewarded for pa/goog-
15-03-2021 payment@ok/Axis Bank Ltd. 6.00 15,895.00
16-03-2021 ASIA/11000012283078_/Yrs 1,300.00 31,320.00
16-03-2021 CMS TRANSACTION CMS/ CMS1862521013/ANGEL BROKING PVT LTD 10,750.00 eSigned using Aadhaar (digio.in) 42,070.00
Date: 2021-03-18 13:46:06 IST
17-03-2021 LIMITED-DM151 90-00030340037242-HDFC0000240 10,000.00 52,070.00
17-03-2021 NET BANKING VIN/GOOGLE Dom/202103171712/107645482667/ 1,014.80 51,055.20
BIL/ONL/000070497282/Zerodha/GNYAZHJ6RCKP
18-03-2021 MV/yes 300.00 50,755.20
MMT/IMPS/107709468952/ZERODHA BR/HDFC
18-03-2021 MOBILE BANKING Bank 1.00 50,756.20
TOTAL 2,54,037.01 2,03,462.94 50,756.20
Account Related Other Information

ACCOUNT TYPE ACCOUNT NUMBER MICR CODE IFSC CODE NAME OF NOMINEE
Savings 047101509584 799229002 ICIC0000471 -
Nominee name is displayed only on specific consent of customer.

Page 5 of 5
For ICICI Bank Limited

Authorised Signatory eSigned using Aadhaar (digio.in)
Date: 2021-03-18 13:46:06 IST
Legends for transactions in your account statement

VAT/MAT/NFS - Cash Withdrawal at other bank's ATM INF - Internet funds transfer in Linked accounts
EBA - Transaction at ICICIDirect BIL - Internet bill payment or Funds transfer to third party
VPS/IPS - Debit card transaction TOP - Mobile Recharge
RTGS - Real Time Gross Settlement (Instant Transfer of Rs 2 Lakh and up to Rs 10 Lakh) NEFT - National Electronic Fund Transfer (Up to Rs 10 Lakh)
• **Mode is available only for transaction done after August 6, 2013.
• As per prevailing guidelines of the Income tax Act, 1961 if a valid PAN is not provided by the •In absence of valid PAN, Form 15G / 15H shall not be treated as valid and tax will be deducted.
Customer then tax shall be deducted at the prevailing rate or 20%, whichever is higher. •In case your PAN is not updated in our record, please visit the nearest branch and provide a copy
•As per guidelines issued by CBDT on May 13, 2011, Form 16A (TDS Certificates) will be generated of the PAN card along with the original PAN card for verification.
through the Income tax website for which the PAN of the customer needs to be necessarily updated •The address of the customer in Form 16A will be the last updated address in the data base of the
in Bank's record. Income tax department.
REGD ADDRESS: LANDMARK, RACE COURSE CIRCLE, VADODARA - 390 007, INDIA www.icicibank.com
This is an authenticated intimation/statement. Category of service: Banking & Financial Services.
Customers are requested to immediately notify the Bank of any discrepancy in the statement Registration No. MIV/ST/Bank & Finc/4.
MHW1-WBG-M-05-Mar-12/148405000053 - 525322040/207/207 - Utility - 1 of 1 PAN Based STC No. AAACI1195HSST001.
Page 1 of 5
MHW1/181D/1-1/WBF-M/03-12
047101509584??DHRI0907 799155
MR.DHRITIMOHAN MITRA Your Base Branch: CHITRAKATHA COMPLEX,BELOW

HOTEL SOMRAJ ,,HGB ROAD,799001
VILL NAYAPALLI PO SARASHIMA BELONIA SOUTH
TRIPURA NEAR SATMURA BAZAR
BELONIYA Visit www.icicibank.com
TRIPURA - INDIA - 799155 Dial your Bank 033-33667777
Date: 2021-03-18 13:46:06 IST
Did you know? It's mandatory to be KYC compliant as per RBI guidelines. If you have not submitted your KYC documents, please visit the nearest
branch or contact your Relationship Manager to complete KYC details for your Account.
Summary of Accounts held under Cust ID: 521839825 as on March 18, 2021
ACCOUNT DETAILS - INR
ACCOUNT TYPE A/c BALANCE(I) FIXED DEPOSITS (LINKED) BAL.(II) TOTAL BALANCE(I+II) NOMINATION
Savings A/c 047101509584 50,756.20 0.00 50,756.20 Registered
TOTAL 50,756.20 0.00 50,756.20
Statement of Transactions in Savings Account Number: 047101509584 in INR for the period September 01, 2020 - March 18, 2021
01-09-2020 B/F 182.13
01-09-2020 ASIA/500100666321_SO/Yes 1,000.00 4,182.13
02-09-2020 R/202009021267437/Yes 149.00 4,033.13
MMT/IMPS/024821543579/Dhriti/SUBHASH
04-09-2020 MOBILE BANKING CH/United Bank Of 5,000.00 9,033.13
08-09-2020 OTHER ATMS NFS/TR02601U/CASH WDL/08-09-20 1,500.00 7,533.13
BIL/002074621312/ICRIB0000100637/ICRIB0000100
14-09-2020 NET BANKING 637 35.00 7,498.13
15-09-2020 R/202009151151630/Yes 149.00 7,349.13
24-09-2020 R/202009241161549/Yes 149.00 5,700.13
24-09-2020 R/202009241862737/Yes 10.00 5,690.13
29-09-2020 047101509584:Int.Pd:29-06-2020 to 28-09-2020 29.00 5,320.13
01-10-2020 ASIA/500105980467_SO/Yes 21,000.00 5,320.13
05-10-2020 OTHER ATMS NFS/TR02601U/CASH WDL/05-10-20 4,500.00 820.13
BIL/002097979332/ICRIB0000100637/ICRIB0000100
14-10-2020 NET BANKING 637 35.00 285.13
BIL/002097979332/IPRU LIFE INSURANCE
14-10-2020 COMPANYLIMITEDGTPRIB 35.00 250.13
UPI/028821170477/JIO20BR0005BM23/jio@yesban
14-10-2020 k/Yes Bank Ltd/ 51.00 199.13
19-10-2020 BIL/REV PMT ID 2097979332 35.00 234.13
Page 2 of 5

19-10-2020 BIL/REV PMT ID 2097979332 35.00 269.13
22-10-2020 LIMITED-DM151 274-00030340037242- 3,000.00 3,269.13
HDFC0000240
22-10-2020 OTHER ATMS NFS/TR0D333U/CASH WDL/22-10-20 2,000.00 1,269.13
BIL/ONL/002105798526/Reliance eSigned using Aadhaar (digio.in)
26-10-2020 R/202010251226769
Date: 2021-03-1821.00
13:46:06 IST 11,248.13
02-11-2020 R/202011021237179/Yes 21.00 11,227.13
16-11-2020 R/202011141264833/Yes 199.00 9,852.13
19-11-2020 ASIA/11000002902187_/Yes 3,000.00 5,352.13
23-11-2020 IN303028XX68499_BIU_DHRITIMOHA 826.00 4,127.13
24-11-2020 R/202011241284202/Yes 51.00 4,076.13
14-12-2020 R/202012121314260/Yes 199.00 14,282.13
VPS/GOMOTI
14-12-2020 DEBIT CARD MOTO/202012131935/034814189033/TRIPURA 5,000.00 9,282.13
VPS/AMWAY
14-12-2020 DEBIT CARD INDIA/202012141604/034910044005/AGARTALA 444.00 8,838.13
MMT/IMPS/034923056489/yes/GIOTTUS/UTIB0CCH
14-12-2020 MOBILE BANKING 274 20,000.00 9,662.13
15-12-2020 ASIA/11000004116667_/Yes 2,500.00 7,162.13
16-12-2020 ASIA/11000004203491_/Yes 2,000.00 5,162.13
17-12-2020 ASIA/11000004244281_/Yes 1,000.00 4,162.13
17-12-2020 ASIA/11000004245906_/Yes 3,000.00 1,162.13
28-12-2020 R/202012251482305/Yes 149.00 1,013.13
30-12-2020 047101509584:Int.Pd:29-09-2020 to 29-12-2020 50.00 19,063.13
02-01-2021 LIMITED-DM151 141-00030340037242- 16,227.01 35,290.14
HDFC0000240
04-01-2021 ASIA/11000005167885_/Yes 6,000.00 29,290.14
05-01-2021 ASIA/11000005253560_/Yes 5,000.00 24,290.14
05-01-2021 BANK CHARGES ATMDEC CHG/25-12-2020/4179+GST 29.50 24,260.64
08-01-2021 R/202101081369242/Yes 555.00 21,205.64
Page 3 of 5

15-01-2021 R/202101151386080/Yes 51.00 19,978.64
18-01-2021 OTHER ATMS NFS/00216015/CASH WDL/18-01-21 1,500.00
Signed by: Dhriti Mohan Mitra 18,079.64
20-01-2021 NET BANKING INF/INFT/023444954511/700006 /ICICI BANK N 50,000.00 Date: 2021-03-18 13:46:06 IST 68,079.64
28-01-2021 ASIA/11000006550522_/Yes 10,000.00 55,378.64
03-02-2021 ASIA/11000006936492_/Yes 4,000.00 95,228.64
BIL/ONL/000038798369/GEEKGARDEN/GYGUUBLN
06-02-2021 86VUVA/Yes 160.00 95,068.64
09-02-2021 ASIA/11000007479744_/Yes 5,000.00 90,068.64
UPI/104014251843/Bakewalacom/razorpay@icici/ICI
09-02-2021 CIBank/ 253.00 89,815.64
UPI/104113418048/Razorpay
10-02-2021 Refund/razorpay@icici/ICICI Bank 253.00 90,068.64
17-02-2021 ASIA/11000008384629_/Yes 2,000.00 85,392.64
17-02-2021 ASIA/11000008391121_/Yes 6,000.00 79,392.64
BIL/ONL/000049094662/Tripura
20-02-2021 St/TSECL_VICI97663/Yes 911.90 75,980.74
01-03-2021 R/202102281494778/Yes 11.00 75,769.74
01-03-2021 ASIA/11000010098561_/Yes 4,000.00 71,769.74
UPI/106311040674/UPI/gourabsarkar182/State Bank
04-03-2021 Of I 1.00 71,770.74
04-03-2021 ASIA/11000010625701_/Yes 5,000.00 66,770.74
04-03-2021 ASIA/11000010629367_/Yes 10,000.00 56,770.74
04-03-2021 ASIA/11000010632363_/Yes 10,000.00 46,770.74
05-03-2021 ASIA/11000010774033_/Yes 5,000.00 41,770.74
05-03-2021 ASIA/11000010810164_/Yes 10,000.00 31,770.74
BIL/ONL/000066503218/Life
12-03-2021 Insur/LIC_VICI9825701/Yes 3,305.74 27,465.00
15-03-2021 R/202103131528331/Yes 21.00 27,268.00
UPI/107411200981/UPI/angelnse@hdfcba/HDFC
15-03-2021 BANK LTD 11,000.00 15,889.00
Page 4 of 5

UPI/107411549654/Rewarded for pa/goog-
15-03-2021 payment@ok/Axis Bank Ltd. 6.00 15,895.00
16-03-2021 ASIA/11000012283078_/Yrs 1,300.00 31,320.00
16-03-2021 CMS TRANSACTION CMS/ CMS1862521013/ANGEL BROKING PVT LTD 10,750.00 eSigned using Aadhaar (digio.in) 42,070.00
Date: 2021-03-18 13:46:06 IST
17-03-2021 LIMITED-DM151 90-00030340037242-HDFC0000240 10,000.00 52,070.00
17-03-2021 NET BANKING VIN/GOOGLE Dom/202103171712/107645482667/ 1,014.80 51,055.20
BIL/ONL/000070497282/Zerodha/GNYAZHJ6RCKP
18-03-2021 MV/yes 300.00 50,755.20
MMT/IMPS/107709468952/ZERODHA BR/HDFC
18-03-2021 MOBILE BANKING Bank 1.00 50,756.20
TOTAL 2,54,037.01 2,03,462.94 50,756.20
Account Related Other Information

ACCOUNT TYPE ACCOUNT NUMBER MICR CODE IFSC CODE NAME OF NOMINEE
Savings 047101509584 799229002 ICIC0000471 -
Nominee name is displayed only on specific consent of customer.

Page 5 of 5
For ICICI Bank Limited

Authorised Signatory eSigned using Aadhaar (digio.in)
Date: 2021-03-18 13:46:06 IST
Legends for transactions in your account statement

VAT/MAT/NFS - Cash Withdrawal at other bank's ATM INF - Internet funds transfer in Linked accounts
EBA - Transaction at ICICIDirect BIL - Internet bill payment or Funds transfer to third party
VPS/IPS - Debit card transaction TOP - Mobile Recharge
RTGS - Real Time Gross Settlement (Instant Transfer of Rs 2 Lakh and up to Rs 10 Lakh) NEFT - National Electronic Fund Transfer (Up to Rs 10 Lakh)
• **Mode is available only for transaction done after August 6, 2013.
• As per prevailing guidelines of the Income tax Act, 1961 if a valid PAN is not provided by the •In absence of valid PAN, Form 15G / 15H shall not be treated as valid and tax will be deducted.
Customer then tax shall be deducted at the prevailing rate or 20%, whichever is higher. •In case your PAN is not updated in our record, please visit the nearest branch and provide a copy
•As per guidelines issued by CBDT on May 13, 2011, Form 16A (TDS Certificates) will be generated of the PAN card along with the original PAN card for verification.
through the Income tax website for which the PAN of the customer needs to be necessarily updated •The address of the customer in Form 16A will be the last updated address in the data base of the
in Bank's record. Income tax department.
REGD ADDRESS: LANDMARK, RACE COURSE CIRCLE, VADODARA - 390 007, INDIA www.icicibank.com
This is an authenticated intimation/statement. Category of service: Banking & Financial Services.
Customers are requested to immediately notify the Bank of any discrepancy in the statement Registration No. MIV/ST/Bank & Finc/4.
MHW1-WBG-M-05-Mar-12/148405000053 - 525322040/207/207 - Utility - 1 of 1 PAN Based STC No. AAACI1195HSST001.
Date: 2021-03-18 13:46:06 IST
Date: 2021-03-18 13:46:06 IST

Instructions / Checklist For Filling KYC Form

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Instructions / checklist for filling KYC form

B. Proof of Identity (POI)

C. Proof of Address (POA)

D. Exemptions/clarifications to PAN (*Sufficient documentary evidence in support of such claims to be collected.)

E. List of people authorized to attest the documents

1 Sign wherever you see

A. KYC form - Document captures the basic information about

10 Annexure - P Additional Rights & Obligations Annexure

2 Sign wherever you see

For office use only (To be filled by the financial institution)

Tick if applicable Residence for tax purposes in jurisdiction(s) outside India

Address KRA VERIFIED

FOR OFFICE USE ONLY

Originals Verified and Self-Attested Document Copies Received

Date Signature of the Authorized Signatory

3 Sign wherever you see

City/Town District Pin Code

City/Town District Pin Code

F. Bank account details

4 Sign wherever you see

J. Dealings through other members

K. Introducer details (optional)

L. Trading preferences / experience

MCX Signed by: Dhriti Mohan Mitra

N. Sales tax registration details (As applicable)

P. Nomination details (Please tick the appropriate options)

5 Sign wherever you see

For office use only

UCC Code allotted to the Client _________________________________________________________________________

Documents verified with Originals Client Interviewed By In-Person Verification done by

Employee Code Z1626 Z1626

Designation of employee Account Opening Account Opening

Signature of the Authorised Signatory

Date : 2021-03-18 Seal/Stamp of the stock broker

6 Sign wherever you see

Signed by: Dhriti Mohan Mitra

7 Sign wherever you see

Signed by: Dhriti Mohan Mitra

Signed by: Dhriti Mohan Mitra

8 Sign wherever you see

Zerodha Commodities Private Limited

9 Sign wherever you see

MR.DHRITIMOHAN MITRA Your Base Branch: CHITRAKATHA COMPLEX,BELOW

DATE MODE** PARTICULARS DEPOSITS WITHDRAWALS BALANCE

DATE MODE** PARTICULARS DEPOSITS WITHDRAWALS BALANCE

DATE MODE** PARTICULARS DEPOSITS WITHDRAWALS BALANCE

Account Related Other Information

Nominee name is displayed only on specific consent of customer.

For ICICI Bank Limited

Signed by: Dhriti Mohan Mitra

Legends for transactions in your account statement

MR.DHRITIMOHAN MITRA Your Base Branch: CHITRAKATHA COMPLEX,BELOW

DATE MODE** PARTICULARS DEPOSITS WITHDRAWALS BALANCE

DATE MODE** PARTICULARS DEPOSITS WITHDRAWALS BALANCE

DATE MODE** PARTICULARS DEPOSITS WITHDRAWALS BALANCE

Account Related Other Information

Nominee name is displayed only on specific consent of customer.

For ICICI Bank Limited

Signed by: Dhriti Mohan Mitra