Common Application Form
App. No.
Time Stamp
Please refer to the general instructions for assistance and complete all sections in English. For legibility, please use BLOCK LETTERS in black or dark ink.
Distributor Code
Sub-Distributor ARN
ARN-
EUIN
Branch Code
Relationship Managers Name
Mobile +91-
Sub-Distributor Code
E-mail
Initial Commission will be paid by the investor directly to the distributor, based on assessment of various factors including the service rendered by the Distributor.
Transaction Charges
Investors Declaration where EUIN is not furnished
SEBI (Mutual Fund) Regulations allow deduction of transaction charges of
Rs. 100/- from your investment for payment to your distributor if your distributor
has opted to receive transaction charges for investments sourced by him. The
transaction charges deductible are Rs. 150/- if you are investing in Mutual Funds
for the rst time. If you are making a SIP Investment, the transaction charges
would be deducted over 3-4 instalments. No transaction charges would be levied
if you are not investing through a Distributor or your investment amount is less
than Rs.10,000/-
I/We conrm that the EUIN box has been intentionally left blank by me/us as
this is an execution only transaction without any interaction or advice by
the employee/relationship manager/sales person of the above distributor and/
or notwithstanding the advice of inappropriateness, if any, provided by the
employee/relationship manager/sales person of distributor and the distributor
has not charged any advisory fees on this transaction.
Sole/1st Applicant
If this is the rst time, you are investing in any mutual fund, please tick here
2nd Applicant
3rd Applicant
1. EXISTING UNIT HOLDERS INFORMATION (If you hold a Folio with L&T Mutual Fund, please furnish the below information and move to Investment & Payment Information section.)
PAN/PEKRN# of Sole/1st Unit Holder
Folio No.
Name of Sole/1st Unit Holder
Mr.
Ms.
M/s
2. NEW APPLICANT(S) PERSONAL INFORMATION
Sole /1st Applicant
Name
Mr.
Ms.
M/s
PAN/PEKRN#
Date of Birth/Incorporation
(Mandatory if rst applicant is a minor)
Guardian (For Minor Investments) / Contact Person (For Non-Individuals)
Name
Mr.
Ms.
PAN/PEKRN#
Relationship with Minor Applicant
Natural Guardian
Court Appointment Guardian
Proof of Date of Birth
Birth Certicate Copy
Passport Copy
Aadhaar Card Copy
Others
Proof of Relationship of Guardian
Birth Certicate Copy
Passport Copy
Court Appointment Order
Others
Mobile No. +91-
(please specify)
(please specify)
E-mail Id*
*Investors providing e-mail id will receive Account Statements, Annual Report & other communication over e-mail. If you however wish to receive this communication in your
registered postal address, please tick here
KYC is mandatory. Please enclose copies of KYC acknowledgement letters for all applicants. #PEKRN required for Micro investments upto Rs. 50,000 in a year.
ADDRESS (Address as per KRA records will overwrite this address if you are KYC compliant)
Correspondence Address
City/Town
Overseas Residence Address (Mandatory for NRIs/PIOs)
City/Town
Pin
Pin
State
State
Tel (R)
Country
Country
(ISD)
Tel (O)
(STD)
(ISD)
Fax
(STD)
(ISD)
(STD)
Tax status of Sole/First Applicant (Please )
Resident Indian Individual
Non Resident Indian Individual (NRI)
Person of Indian Origin (PIO)
Foreign Portfolio Investor (FPI)
Foreign National Residing in India
Company/Body Corporate
Financial Institutions
Limited Liability Partnership (LLP)
Partnership Firm
Foreign Institutional Investor (FII)
Defence Establishment
Hindu Undivided Family (HUF)
Non Govt. Organization (NGO)
Association of Persons (AOP)/Body of Individuals(BOI)
Trust
Are you a Non Prot Organization (NPO)
Bank
Society
Mutual Fund
Others
Yes
No
ACKNOWLEDGEMENT SLIP (To be lled in by the Applicant)
Received from
an application for
investment in Scheme L&T
Investment Type ()
Lumpsum
SIP
Micro SIP
Investment Cheque Details : Cheque No.
Drawn on Bank
App. No.
Option
Multi-Scheme SIP
Rs.
Branch
For Ofce Use Only
Dated D D M M Y Y Y Y
City
Acknowledgement
Stamp & Date
BANK ACCOUNT INFORMATION (Mandatory for receiving Redemption/Dividend payments)
Account Number
Account Type
Savings
Current
NRE
NRO
FCNR
Others
Bank Name
Branch
City
IFSC
MICR
If you are not making the investment from the above mentioned bank account, please attach an original cancelled cheque leaf of the above account with the
name of the rst holder printed.
3. MODE OF HOLDING
Please
Sole/1st Holder only
Any one or Survivor
Joint
(If the mode of operation is not specied above, for folios opened with more than one applicant, the mode of operation would be taken as Any one or Survivor)
4. DETAILS OF OTHER APPLICANT(S) (Please note that where the sole/1st applicant is a minor, no joint holders are allowed)
2nd Applicant
Name
Ms. F
Mr.
PAN/PEKRN#
Date of Birth
E-mail Id
3rd Applicant
Name
Ms. F
Mr.
PAN/PEKRN#
Date of Birth
KYC is mandatory. Please enclose copies of KYC acknowledgement letters for all applicants.
#PEKRN
E-mail Id
required for Micro investments upto Rs. 50,000 in a year.
5. POWER OF ATTORNEY (PoA) HOLDER DETAILS
If your investment is being made by a Constituted Attorney on your behalf, please furnish the below details and enclose a notarised copy of the Power of Attorney for registering
the same:
POA Holders Name
POA for
Mr.
Ms.
Sole / First Applicant
Second Applicant
Third Applicant
Date of Birth
E-mail Id
PAN of POA Holder
(POA Holder needs to comply with applicable KYC requirements)
6. INVESTMENT & PAYMENT INFORMATION (Please ensure that the cheque complies to the CTS 2010 standards)
Lumpsum
Investment Type ()
SIP
Micro SIP
(Also ll & attach SIP Investment Form)
Multi-Scheme SIP (Please ll Multi-Scheme SIP Investment Form)
For Lumpsum & SIP Investment (Please issue cheque favouring scheme name)
Scheme Name L&T
Option ()
Dividend Frequency (wherever applicable)
Payment Mode :
Cheque / DD / Pay Order
Daily
Weekly
Monthly*
Electronic Transfer
Growth*
Quarterly
Dividend Reinvestment
Annual^
Dividend Payout
Semi-Annual^
One Time Mandate (OTM)
(Default plan / option / sup option will be applied incase of no information, ambiguity or discrepancy)
Instrument Date D D M M Y Y Y Y
Instrument No.
Bank Name
Drawn On
UTR No.
Bank Branch
Investment Amount (`)
DD Charges (if applicable `)
Account Type
Saving
Bank City
Current
NRE
NRO
Net Amount (`)
*Default option if not selected
^Available in select schemes only
Subject to realisation of cheque and furnishing of mandatory information/documents. Please retain this slip till you receive your Account Statement.
call 1800 2000 400 or 1800 4190 200
email investor.line@lntmf.co.in
www.lntmf.com
Please note our lines are open from 9 am to 6 pm, Monday to Friday and 9 am to 1 pm on Saturday
2
FCNR
Document attached to avoid Third Party Payment rejection, where applicable :
Bankers Certicate, for DD
Third Party Declaration
For Multi-Scheme SIP (Please issue cheque favouring L&T MF Multi-Scheme SIP)
Scheme 1
L&T
Option ()
Dividend
Frequency
Scheme 2
Growth*
Dividend Payout
Dividend Reinvestment
Growth*
Dividend Payout
Dividend Reinvestment
Growth*
Dividend Payout
Dividend Reinvestment
SIP Amount (`)
L&T
Option ()
Dividend
SIP Amount (`)
Frequency
Scheme 3
Dividend
Frequency
L&T
Option ()
SIP Amount (`)
Payment Mode :
Cheque / DD / Pay Order
Electronic Transfer
Bank Name
Drawn On
Instrument Date D D M M Y Y Y Y
Instrument No.
Bank Branch
Bank City
UTR No.
Account Type
Investment Amount (`)
Saving
Current
NRE
NRO
FCNR
DD Charges (if applicable `)
Net Amount (`)
*Default option if not selected
^Available in select schemes only
7. DEMAT ACCOUNT INFORMATION (Mandatory for crediting units in demat account)
If you wish to hold your investment in dematerialised mode please furnish the below details and enclose a copy of the Client Master that you may have received from your
Depository Participant.
Depository (Please any one)
NSDL
OR
CDSL
Depository Participant Name
Depository Participant ID
Beneciary A/c No.
8. KYC DETAILS (Mandatory. If left blank the application is liable to be rejected)
Below 1 lac
For First Applicant/
Guardian
1-5 Lacs
10-25 Lacs
25 Lacs - 1 crore
> 1 Crore
as on D D / M M / Y Y Y Y (Not older than 1 year) (Mandatory for Non-Individuals)
Net-worth (`)
Gross Annual
Income
(For Individuals
and Non
Individuals)
5-10 Lacs
Below 1 lac
1-5 Lacs
5-10 Lacs
10-25 Lacs
25 Lacs - 1 crore
> 1 Crore
For Second Applicant
as on D D / M M / Y Y Y Y (Not older than 1 year)
Net-worth (`)
Below 1 lac
1-5 Lacs
5-10 Lacs
10-25 Lacs
25 Lacs - 1 crore
> 1 Crore
For Third Applicant
as on D D / M M / Y Y Y Y (Not older than 1 year)
Net-worth (`)
Occupation
Details
(For Individuals
only)
For First Applicant/
Private Sector Service
Public Sector Service
Government Service
Business
Guardian
Housewife
Student
Forex Dealer
Agriculturist
For Second Applicant
For Third Applicant
Others
(For Individuals
only)
Retired
Private Sector Service
Public Sector Service
Government Service
Business
Housewife
Student
Forex Dealer
Agriculturist
Retired
Private Sector Service
Public Sector Service
Government Service
Business
Housewife
Student
Forex Dealer
Agriculturist
Retired
(For
Professional
Please specify
Others
Professional
Please specify
Others
For First Applicant/ Guardian
I am politically Exposed Person
I am Related to Politically Exposed Person
Not Applicable
For Second Applicant
I am politically Exposed Person
I am Related to Politically Exposed Person
Not Applicable
For Third Applicant
I am politically Exposed Person
I am Related to Politically Exposed Person
Not Applicable
Is the company a Listed Company or Subsidiary of Listed Company or Controlled by a Listed Company
Others
Professional
Please specify
Others
YES
NO
(If No, please attach Ultimate Beneciary Ownership Declaration mandatorily)
If the Entity involved/providing any of the following services:
Non-Individuals
Gaming/Gambling/Lottery/Casino Services
YES
NO
only)
Foreign Exchange/ Money Changer Services
YES
NO
Money Lending/Pawning
YES
NO
9. INFORMATION REQUIRED FOR TAX REPORTING (Mandatory. If left blank the application is liable to be rejected)
FOR INDIVIDUALS:
The below information is required for all applicant(s)/Guardian including Sole proprietor and POA Holder.
Sole/First Applicant/Guardian
I am a tax resident of India and not a resident of any
other country
Second Applicant
Third Applicant
POA Holder
Yes
Yes
Yes
Yes
No
No
No
No
If No, please mandatorily enclose the FATCA & CRS Declaration for Individual Investors.
FOR NON-INDIVIDUALS: Please mandatorily enclose the FATCA, CRS & UBO Declaration for Non Individuals with all the sections lled.
10. NOMINATION DETAILS (Please note that where the sole/1st applicant is a minor, no nomination is allowed)
(Please )
I/We wish to Nominate
I/We do not wish to Nominate
I/We wish to appoint Multiple Nominees (Please ll the Nomination Form separately)
Name of the Nominee
In case nominee is a minor, please ll : Date of Birth
Relationship with the
Applicant
Name of the Guardian
Address of the Nomine
Address of the Guardian
City/Town
City/Town
State
State
Pin
Country
D D M M Y Y Y Y
Pin
Country
Signature of the Nominee
Signature of the Guardian
9. DECLARATION & SIGNATURES
I/We have read and understood the contents of the Scheme Information Document, Statement of Additional Information and Key Information Memorandum of the aforesaid Scheme(s)
of L&T Mutual Fund including the sections on Who cannot invest, Foreign Account Tax Compliance Act (FATCA) / Common Reporting Standard (CRS) (Reporting Guidelines) and
Important Note on Anti Money Laundering, Know-Your-Customer and Investor Protection. I/We hereby apply for allotment/purchase of Units in the Scheme(s) and agree to abide by the
terms and conditions applicable thereto. I/We hereby declare that I/We am/are authorised to make this investment and that the amount invested in the Scheme(s) is through legitimate
sources only and does not involve and is not designed for the purpose of any contravention or evasion of any Act, Rules, Regulations, Notications or Directions issued by any authority
in India. I/We hereby authorise L&T Mutual Fund (the Fund), its Investment Manager (LTIM) and its agents to disclose details of my investment to my bank(s)/ Funds bank(s) and/or
Distributor/Broker/Investment Adviser/any governmental or regulatory authority. The ARN holder has disclosed to me/us all the commissions (in the form of trail commission or any other
mode), payable to him for the different competing schemes of various Mutual Funds from amongst which the Scheme(s) is being recommended to me/us. I/We have neither received nor
been induced by any rebate or gifts, directly or indirectly, in making this investment. I/We declare that the information given in this application form is correct, complete and truly stated.
I/We accept and agree to abide by the terms and conditions (as mentioned on HYPERLINK http://www.lntmf.com www.lntmf.com) with respect to my/our dealings with L&T Mutual Fund/
its Investment Manager through various channels.
In case there is any change in the information (especially pertaining to Reporting Guidelines) already provided to LTIM / Fund, I/We agree that I/We shall inform the same to LTIM/Fund
within 30 days of the change. I/We authorize updation of the records (including pertaining to the Reporting Guidelines) basis the information / documents received by LTIM/Fund/Registrar
and Transfer Agent (RTA) from other SEBI Registered Intermediaries. I/We authorize LTIML/Fund/RTA, to share the information provided by me / us with other SEBI Registered
Intermediaries to facilitate single submission /updation. I / We authorize LTIM/ Fund/RTA to provide relevant information to upstream payors to enable withholding to occur and pay out
any sums from the my/our account or close or suspend my/our account(s) under intimation me/us.
APPLICABLE FOR NON-ADVISORY TRANSACTIONS ONLY:
I/We, hereby acknowledge and conrm that the above transaction is Execution Only as explained vide SEBI Circular No. CIR/IMD/DF/13/2011 dated 22 August 2011. This investment
is being made notwithstanding the advice of the appropriateness/inappropriateness of the same. On such transaction(s), I am not being charged any kind of transaction fee(s) by the
AMFI registered distributor. On this transaction, the distributor would be compensated by the Mutual Fund House/Asset Management Company concerned in lines with the commission
rate(s)disclosed by the distributor.
*APPLICABLE FOR NRIs/PIOs/FIIs/FPIs INVESTING ON REPATRIATION BASIS ONLY: I/We conrm that I am/we are Non-Resident(s) of Indian Nationality/Origin and that I/We have
remitted funds from abroad through approved banking channels or from funds in my/our NRE/FCNR Account. I/We undertake that all additional purchases made under this folio will also
be from funds received from abroad through approved banking channels or from funds in my/our NRE/FCNR Account.
Date: D D M M Y
4
Sole/First Applicant/Guardian
Second Applicant
Third Applicant
