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ht nder
Pre"ention of #oney Landerin! A$t% &''&% the rles notified therender and the Reser"e Ban( of India )RBI*
!idelines on Anti #oney Landerin! and in "ie+ of the Poli$y Gidelines for issan$e and o,eration of Pre,aid
Payment Instrments in India issed -y RBI% rele"ant for issan$e of ,re,aid "o$hers.
KNOW YOUR CUSTOMER (KYC) FORM KNOW YOUR CUSTOMER (KYC) FORM
Full Name of the Customer
)as a,,earin! in the do$ment atta$hed*
#r. .
#rs..
#s.
Mobile Number
Complete Postal !!ress
)as a,,earin! in the do$ment atta$hed*
State"
Please affi/ re$ent $olor
,hoto!ra,h and si!n
a$ross the ,hoto!ra,h
P#N
Email #!"
$ate of %irth(!!&mm&'')
(e)!er" # 0
PN In $ase% yo don1t ha"e PAN ,lease fill
0orm 2' )Anne/re 3 I*
#!e)tit' Proof
)Self Attested*
)S-mit any ONE of the *ali! !o+ume)ts and ti$( )* a!ainst the do$ment atta$hed*
4ri"er1s Li$ense 5oter1s I4 Card Pass,ort PAN
!!ress Proof
)Self Attested*
4ri"er1s Li$ense 5oter1s I4 Card Pass,ort Ration Card
Ban( Statement. Pass-oo( Ele$tri$ity .#o-ile .Tele,hone Bill
(ross ))ual #)+ome
6,to Rs. 7%''%'''
Rs.7%''%''8 9 a-o"e
O++upatio)
Pri"ate Se$tor Ser"i$e Go"ernment . P-li$ Se$tor Bsiness
Professional Hose #a(er Stdent Retired Others
4e$laration: I a!ree to a-ide -y the terms% $onditions% rles% re!lations 9 other stattory re;irement a,,li$a-le to Pre,aid Payment Instrments
issed -y <i,Cash Card Ser"i$es P"t. Ltd. )=<CSPL>*. I here-y de$lare that the ,arti$lars !i"en herein are tre% $orre$t and $om,lete to the -est of my
(no+led!e and -elief% the do$ments s-mitted alon! +ith this a,,li$ation are !enine and I am not ma(in! this a,,li$ation for the ,r,ose of
$ontra"ention of any A$t% Rles% Re!lations or any statte or le!islation or any Notifi$ations% 4ire$tions issed -y any !o"ernmental or stattory
athority from time to time. I here-y nderta(e to ,rom,tly intimate <CSPL% of any $han!es in the information ,ro"ided herein a-o"e 9 a!ree and
a$$e,t that <CSPL is not lia-le or res,onsi-le for any losses% $osts% dama!es arisin! ot of any a$tions nderta(en or a$ti"ities ,erformed -y them on
the -asis of the information ,ro"ided -y me as also de to my not intimatin! .delay in intimatin! s$h $han!es. I here-y athori?e <CSPL to dis$lose%
share% remit in any form% mode or manner% all.any of the information ,ro"ided -y me to <CSPL for issan$e of Pre,aid Payment Instrment in +hi$h I
may transa$t in$ldin! all $han!es% ,dates to s$h information as 9 +hen ,ro"ided -y me. I here-y a!ree to ,ro"ide any additional
information.do$mentation that may -e re;ired -y <CSPL or its athori?ed a!ents% in $onne$tion +ith this form.
4ate:
Pla$e:
Si!natre of the Cstomer
)as a,,earin! in the do$ment atta$hed*
Note:
8. The ma/imm limit for <i,Cash is Rs.7''''.@ &. Co,ons are "alid for 2 months from the date of ,r$hase.
A. 0or any assistan$e or en;iries ,lease $onta$t '&&@22B& ''''. C. By transa$tin! yo a!ree to the terms and $onditions on +++.?i,$ash.in
FOR OFFICE USE ONLY VERIFIED BY & DATE REFERENCE NO:
NNE,URE & #
FORM No- ./
(See se+o)! pro*iso to rule 001 %)
Form of !e+laratio) to be fille! b' a perso) 2ho !oes )ot ha*e a perma)e)t a++ou)t )umber a)! 2ho
e)ters i)to a)' tra)sa+tio) spe+ifie! i) rule 001%
8 0ll Name 9 Address of the
de$larant
:
& Parti$lars of transa$tion :
A Amont of transa$tion :
C Are yo assessed to ta/D : Ees No
7 If yes%
i. 4etails of the +ard . Cir$le .
Ran!e +here the last retrn of
in$ome +as filed
ii. Reasons for ha"in!
,ermanent a$$ont nm-er
:
2 4etails of do$ment -ein! ,rod$ed
in s,,ort of address in $olmn )8*
:
Verification
I% do here-y de$lare that +hat is stated a-o"e is tre to the
-est of my (no+led!e and -elief.
5erified today% the day of
4ate:

Pla$e: S#(NTURE OF T3E $EC4RNT
#)stru+tio)s: 4o$ments +hi$h $an -e ,rod$ed in s,,ort of the identity are:
Pass,ort
4ri"in! Li$ense
5oter1s I4
Certifi$ate of identity si!ned -y #P or #LA or #ni$i,al Con$ilor or Ga?etted Offi$er.
FOR OFFICE USE ONLY VERIFIED BY & DATE REFERENCE NO: