Common Request Form

( Kindly fill the form in Capital Letters only )

Service Request No.

CRN Corporate CRN Date D D MM Y Y Y Y

CASA Account Number

I / We

Mr./ Ms. FIRST NAME MIDDLE NAME LAST NAME

Mr./ Ms. FIRST NAME MIDDLE NAME LAST NAME

request you to process the requests as per the details provided below.

1. Account Related

Cheque Book Issuance At-Par Number of Cheque books

Statement for the period D D MM Y Y Y Y to D D M M Y Y Y Y Physical statement E-mail statement

Passbook Related Requests Register & Issue Passbook Duplicate Passbook Issuance Cancel the Passbook Issuance

Cheque book not received request placed through requisition slip / Call Centre / Internet Banking / ATM Dropbox on ___ / ____ / ______

Bankers Verification Signature Photo Address Purpose

Cancellation/Revalidation of Demand Draft / Banker’s Cheque Drawn on DD/BC No

(Please enclose original demand draft / banker’s cheque) Dated Amount Favouring

2. Certificate / Report Related

Interest Certificate TD CASA For the period

Balance Certificate TD CASA Both For the period

Confidential Report Paid Cheque Report Credit Confirmation For the period Purpose

3. Stop Payment

Stop Payment Stop Payment for Cheque No. from to

Value of Cheque Date of Cheque Payee Name

Reason for Stop Payment

Erroneous credit / debit in account:

Cheque No. Date Amount

Drawn on

Details of Debit / Credit:

Date of Txn Amount

Payee details required:

Cheque No. Date Amount

:
Returned cheque not received

Cheque No. Date Amount

Drawn on deposited at

Any Other Request

Signature(s)

1st Account Holder 2nd Account Holder 3rd Account Holder 4th Account Holder
In case of Non-Individuals, please affix In case of Non-Individuals, please affix In case of Non-Individuals, please affix In case of Non-Individuals, please affix
Company Seal Company Seal Company Seal Company Seal

(For Individuals - at Account level changes, all the account holders need to sign whereas at CRN level changes, respective CRN holder has to sign. For
Non-Individual, signatures as per MOP required.)
Important:
Requests will be processed subject to fulfillment of all requirements and information being complete.
Terms and conditions and rules for services apply
Service charges, if any, will be as per bank’s schedule of charges
Please place a separate request if there is a change in correspondence address along with new address proof.

For Bank Use only

Date of Acceptance D D M M Y Y Y Y Sol ID

Signature verified by Sign & Emp Code Receiver’s stamp

Documents sent to CPC / RPC on D D M M Y Y Y Y Authorized by

Declaration
I have voluntarily supplied the above information which I acknowledge that the Bank is required to obtain to provide its products and services to me. I have gone through the
Privacy Notice published by the Bank on its website www.kotak.com and having agreed to the same I hereby give my consent in favour of the Bank to process my personal
KMBL/Feb-25/V1.02

information for the purposes and in the manner provided in the Privacy Notice while I avail various products and services from the Bank.

Signature Date

Acknowledgement Slip

We acknowledge the receipt of Customer Request / Complaint instruction from Mr. /Mrs. / Ms.

relating to customer relationship number under service request number

Date: Bank Official (Sign and stamp)

Kotak Mahindra Bank Ltd.,CIN: L65110MH1985PLC038137