ACCOUNT CLOSURE REQUEST FORM
Application No. 16901046765751524 Date 2 1 0 2 2 0 2 4
Closure Initiated by ❑ BO ❑ DP ❑ CDSL
(To be filled by the BO. Please fill all the details in Block Letters in English)
To,
Depository Participant Name
Address
Dear Sir / Madam,
I / We the Sole Holder / Joint Holders / Guardian (in case of Minor) / Clearing Member request you to close my / our account with
you from the date of this application. The details of my/our account are given below:
Account Holder’s Details
DP ID 1 2 0 8 8 8 0 0 Client ID 2 7 7 1 3 5 1 6
Name of the First / Sole Holder KOWWURU GOUTAM
Name of the Second Holder NA
Name of the Third Holder NA
Address for Correspondence S/O K JAGANNATH RAO, 9/D, WARD 30, STREET 28 , SECTOR 11, ZONE 2,
KHURSIPAR BHILAI, DURG, CHHATTISGARH
City BHILAI State CHHATTISGARH PIN 4 9 0 0 1 1
Details of remaining security balances in the account (if any)
Reasons for Closing the Account I CREATED IT BY MISTAKE.
Balance remaining in the account (if any) to be :
❑ Partly rematerialized and partly transferred. ❑ Rematerialized
❑ Transferred to another account (Number given below) ❑ Not applicable
DP ID Client ID
Balance present in a/c for ❑ Ear - marked ❑ Pledged
(To be filled by DP, if applicable) ❑ Pending for Dematerialization ❑ Frozen
❑ Pending for Rematerialisation ❑ Lock-in
First / Sole Holder Second Holder Third Holder
Name KOWWURU GOUTAM NA NA
Signature *
*If DP or CDSL initiates account closure, Signature(s) of account holder(s) not required.
===============================(Please Tear Hear)==============================
Acknowledgement Receipt
Application No.: Date:
We hereby acknowledge the receipt of your instruction for Closing the following Account subject to verification: -
DP ID Client ID
Name of the First / Sole Holder
Name of the Second Holder
Name of the Third Holder
Reason for Closure
Depository Participant Seal and Signature
Instructions to Account Holder(s)
o Submit a duly-filled RRF if the balances are to be rematerialized.
o Submit a duly-filled transfer form (off market instruction slip) if the balances are to be transferred to another A/c.
Paytm Money Limited, The Hub, 8/2, Sarjapur Main Road, Ambulipura Village, Varthur Hobli, Bengaluru - 560103
