KYC SELF DECLARATION

To
DCM Financial Services Ltd
New Delhi

Please affix and

sign across your
recent
photograph

Dear Sir
My FD/NCD No: ..
I ______________________________________________________________Account holder)/Constituted Attorney of
__________________________________________________________________(Account holder) do hereby solemnly
declare that the information provided below with respect to the above account is set up to date and correct. The documents
provided, as proof of indemnity and proof of address have been self-attested. I have also attached my recent photograph above.
RESIDENTIAL ADDRESS
Flat No.& Bldg.Name:_____________________________________________________________________________
Road No./Name
: _____________________________________________________________________________
Area & Landmark : _____________________________________________________________________________
City
: _____________________________________________________________________________
Pin Code
: ___________________
Telephone:(Res)__________ ______________(Off.)___________ ______________
(STD Code)
(STD Code)
Mobile No: __________________
E-mail:
_______________________________________________________________________________________
MAILING ADDRESS(if different from the residential address):
Flat No.& Bldg.Name:
________________________________________________________________________
Road No./Name
:
________________________________________________________________________
Area & Landmark :
________________________________________________________________________
City
:
________________________________________________________________________
Pin Code
:
______________________
Telephone:(Res)__________ ______________(Off.)___________ ______________
(STD Code)
(STD Code)
Mobile No: __________________
E-mail:
_________________________________________________________________
I confirm having enclosed a self-attested copy of the following documents as the proof of identity and proof of address
(please tick the relevant document in the list below):
Proof of Identity (any one)
Proof of Residential Address (any one)

Passport
Voters ID
Driving License
Photo Pan Card
Photo Ration Card
Government ID Card
Defence ID Card

Passport
Voters ID
Driving License
Latest Electricity Bill
Latest (Mobile/Landline)
Ration Card
Life Insurance Policy

Please provide separate documents for proof of identity and proof of residential address. Only a valid passport will
be accepted as both.
Full Name of the
Account Holder : ______________________________________________________
PAN Number :
___________________________________
(Mandatory)
Date this ___________ Day of ______________________________

Signature of the FD/NCD/Constituted Attorney : (As

per the mandate provided to the company)
Note: In case of joint accounts or accounts operated under a power of attorney a separate declaration should be completed for each joint account
holder or constituted attorney.
For Change of address, to be attached with application .