Service Request No.

Date
Name and Signature Deletion
( For Resident Individuals)

Account Holder Details

I/We hold Savings Account
(Please fill in all the details in CAPITAL LETTERS and use BLACK INK only. Fields with(*) are mandatory)

First Name Middle Name Last Name

*Name:(Applicant Name):

Customer Declaration
I/ We wish to request you to delete the Name & Signature of the below mentioned applicant and update mode of operation in the
above mentioned account.
First Name Middle Name Last Name
Name:
I/ We hereby understand that:
Existing Net banking user ID and password can be continued or can change the credentials if required
 Bank shall not honour cheques issued by the above holder to debit the above mentioned account.
 ATM/ Debit card number of the above account holder__________________________________________ is hereby surrendered/
has been lost/misplaced/and the same may be treated as cancelled.
 All the unused cheque book series__________________________________________ will be destroyed.
 Modification shall be applicable to all the accounts under the given Customer ID

Mode of Operation: Singly Either or Survivor Jointly Others______________________________________

(Please specify)

Father’s Name:
Applicant DOB: Reason for Name Deletion: Deceased Others
Mother’s Maiden Name:
PAN: Form 60
Communication address: There is no change in my address I wish to change in my address as below

City: State:
Pin code: Tel No. (res.):

Tel No. (off): *Mobile No:

Permanent Address:

City: State:

Pin code: Tel No. (Res.): Tel (off.):

# For change of address, please submit relevant address proof which will be verified with the original by officials.
*E-mail ID :
I wish to register for E-mail statement : Yes No

Customer Declaration for Nomination

Nomination under Section 45ZA of the Banking Regulation Act1949, and rule 2 (1) of the Banking Companies (Nomination) Rules 1985, with respect of bank
deposits, name & address(es)

I/We, __________________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________________

nominate the following person to whom in the event of my/our/minor's death the amount of the deposit, particulars where of are given below, may be returned by
ICICI Bank Ltd. (Name and address of branch in which deposit is held)________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________________

Checking your account balance or requesting a mini statement, banking is now easy as messaging a friend. With SMS, you can stay in touch with your
account with just a few key words. Simply SMS the following keywords to 9215676766
• Balance Enquiry : IBAL
• Last 3 transactions : ITRAN
• Cheque Status Enquiry : ICSI Cheque No.
• Stop Cheque Request : ISCR Cheque No.
• Cheque Book Request : ICBR
• View Presented Bills : IVIEW (space) Biller Nickname
I/ We request you to print nominee's name in the account/deposits, maintained with bank Yes No

Nominee Details
Name and Address of Nominee Relationships with depositor, if any Age DOB of Nominee

As the nominee is a minor on this date, I/We appoint __________________________________________________________________

residing at ________________________________________________________________________________________________ and age in
years as _____________________ to receive the amount of the deposit in the account on behalf of the nominee in the event of
my/ our/ minor's death during the minority of the nominee.
Deposit Details
Nature of Deposit Account Number / Customer Id Additional Details, if any

No Nomination Declaration (Applicable only incase of Single applicant)

As per RBI guidelines, I/we confirm that I/we have been explained about the benefits of the nomination facility for my/our bank account by Bank
official. However, I/we state that in spite of the explanation of the benefits, I/we do not want to nominate any person to my/our Bank Account.
I/we have read and understood the terms and conditions governing the above account

Customer Signature (s)

Signature Signature Signature

Name Name Name

*(Primary Applicant) *(Joint Applicant 1) *(Joint Applicant 2)
(BSR code) Business Statistical Report (To be filled by Bank Official)
BSR code: (For Joint account holders)
Occupation Male Female
Agri Allied/ Farmers (Land holding Nil, <= 5 acres, >5acres) 41141 41142
Business: Manufacturing Trading Services Retailing Agriculture Real Estate
Professional Doctor, CA/CS, Lawyer, Architect, Consultant, Engineer Housewife, Retired, Student 41241 41242
Business: Shroff / Moneylenders, Stock Broker, Dealers in Bullion) 41441 41442
Salaried: Proprietorship, Partnership, Pvt. Ltd., Public Ltd., Public Sector, Government,
Multinational, Wage Salary earners, others) 41341 41342

For Branch Use Only

Declaration From the Branch Official – I confirm:
Joint Customer ID exist in the account Yes No (If “No”, AOF and KYC documents are required)
In case photo is not available for joint holder(s), then AOF to be obtained
If Primary holder is getting deleted, then complete AOF form, MITC and KYC documents for other holders to be obtained
If continuing holders are 2 and more then, use photocopies of this form
The details match with the Bank's records
The applicant(s) signed in my presence and the signature(s) have been verified with the Bank records
The account is not inactive/Dormant/Frozen/in Debit balance
The account is not linked with I-direct facility
BM authorization obtained on death certificate (If applicable)
Nomination/no nominee declaration obtained in case of single applicant

Customer ID* Status Code Bank

Seal
Employee Name & Employee ID:_____________________________________________
Signature of Employee:______________________________________________________ ICICI/CSBB/V2.0/1017/LIAB/NAMESIGNDEL

Acknowledgement Slip (To be filled by the Bank staff)

Received from _______________________________________________________________________ Date
A/c No. ___________________________________________________________________for Name and Signature deletion.
ICICI Bank Branch Name:_____________________________________________ Bank
Seal
Signature of Bank Official:______________________________________________