Please take due care & fill in all the details in CAPITAL LETTERS only.

A completed & correctly filled in Form will help us in processing your Application
faster. An incomplete / incorrect Application is liable to be rejected.

PERSONAL INFORMATION
APPLICANT
Surname

Full Name

CO-APPLICANT

First Name

Middle Name

Surname

First Name

Middle Name

Father’s Name
Date of Birth, Age, & Sex

DD
Age:

MM

DD

YYYY

years Male

Female

Age:

MM

YYYY
Female

years Male

Income Tax PAN
[attach Xerox Copy]
Place of Birth
Marital Status

Single

Married

Others

Single

Married

Others

Exact Educational Qualif. (pl. specify)
Identity Proof (for Non-IT Assessees) – Passport
any one [attach Xerox Copy]

Voters ID

Photo Credit Card

Driving Licence
Employee ID Card

No. ________________
Category
Dependents
Residence Address

SC / ST

OBC

Passport

Voters ID

Driving Licence

Photo Credit Card

Employee ID Card

No. ________________
Others

SC / ST

OBC

Others

Please specify Relation of Co-applicant with Applicant: ___________________________________________
No. of Dependents: Children ____________________________ Adults _____________________________.
_______________________________________________________________________________________
_______________________________________________________________________________________
Dist. ___________________________ State ___________________________ PIN
Nearest Landmark _____________________________ STD Code _________ Ph. # ___________________
Mob. # _________________________ E-mail ID ________________________________________________
Residence Status:

Owned

Rented

Company Quarters

No. of years at above Residence __________________ If rented, Rent p.m. __________________________
Permanent Address

_______________________________________________________________________________________
_______________________________________________________________________________________
Dist. ___________________________ State ___________________________ PIN
Nearest Landmark ___________________________ STD Code __________ Ph. # ____________________

Office Address

___________________________________________ ___________________________________________
___________________________________________ ___________________________________________
Dist. _______________ State __________________ Dist. _______________ State __________________
PIN

STD Code __________ PIN

STD Code __________

Ph. # _________________ FAX _________________ Ph. # _________________ FAX _________________
Details of Loans availed: [Please attach separate sheet if space is insufficient]
Name of Bank / FI / Sanc. Date, ROI, Term, & Purpose Details of Security Offered
Employer

Sanc. Amt. / Limit

EMI

O/s. Bal. as on Date

Have you / your Spouse ever stood as Guarantor? Yes
No
If yes, give details: _________________________________________________________________________________________________________
1

(2) Self-employed Persons / Professionals should attach the copies of ITRs.a. / ECS / PDC / Collecting Bank Due Date of EMI: Purpose of Loan: Whether to start EMI immediately {required only in case of Const. ______________ State ___________________ Dist. specify) Monthly Expenses: Rs.] FULL ADDRESS OF THE PROPERTY ________________________________________________________________________________________ ________________________________________________________________________________________________________________________ Nearest Landmark ____________________________ Dist. Are you a Shareholder of LICHFL? Yes / Are you opting for Griha Suraksha (Group Mortgage Redemption Assurance Scheme)? Yes / No No Bank A/c. Ft. Rs. ___________________ State _______________________ PIN Area of Land / Undivided Share of Land: ____________________ Sq.): Type of Rate of Interest: Floating / Fixed-3 / Fixed-5 / Fixed-10 Term Desired (Max.] Name of the A/c. Department Date of Joining DD Total Experience _______________ Years MM YYYY DD MM YYYY _______________ Years Retirement Year Gross Annual Income Rs. Income Computation Statements. Policies / PLI Other Properties Shares & Securities Current Balance in PF / PPF Other Assets (Pl.INCOME INFORMATION APPLICANT Type of Employment Salaried CO-APPLICANT Self-employed Salaried Professional Retired / Homemaker / Student / Others Name & Contact Details Self-employed Professional Retired / Homemaker / Student / Others of ___________________________________________ ___________________________________________ Organisation ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ Nearest Landmark ___________________________ Nearest Landmark ___________________________ Dist.] Life Ins. along with a Note on the Business / Professional Activities.a. Note: (1) Salaried Employees should attach copies of last 3 Months Payslips along with copies of Form 16 & ITR of the latest Assessment Year.p. /. ______________ FAX _______________ E-mail: _____________________________________ E-mail: _____________________________________ Contact Person ______________________________ Contact Person ______________________________ Designation & Employee No. Ft.] Bank Savings / Deposits Particulars Applicant [Rs. Details [Please attach copies of Bank Statements for at least past 6 Months. Holder PROPERTY INFORMATION Name & Address of the Bank Type of Account Account No. /. 20 years): Mode of Payment of EMI: Salary Ded. [Please attach copies of Title Documents.p.p. /. ______________ State ___________________ STD Code __________ STD Code __________ PIN PIN Phone No. Built-up Area: ____________ Sq.] Co-applicant [Rs. of Expiry of Lease : ______________ 2 .m. Name (s) of Owner (s): _____________________________________________________________________________________________________ Name of Lessor: _____________________________________________ Term of Lease: _____________ Dt.] Co-applicant [Rs. Net Annual Income Rs. _____________________/.}? Yes Purchase of New Flat Purchase of Flat Resold Construction of New House Purchase of Ready House Extension of House / Flat Improvement / Renovation Purchase of Plot Plot Purchase + House Construction No FINANCIAL INFORMATION Particulars Applicant [Rs.a. & full set of Financials for the last 3 Assessment Years. ______________ FAX _______________ Phone No. LOAN INFORMATION Loan Required (Rs. Ft. Rs. /.a. Carpet Area: ____________ Sq.p.p.

# (R) _______________________________ STD Code ___________ Ph. even after payment of such Fee. of Const. I / We have no Insolvency Proceedings against me / us nor have I / we ever been adjudicated Insolvent and further confirm that I / we have read the LICHFL Brochure giving details of its Loan Schemes and understood its contents. I / we am / are aware that the Loan Cheque will be given in the favour of the Vendor only and I / we agree to this procedure. # (R) _______________________________ Ph. and the Loan Sanction or Rejection is at the sole discretion of LICHFL.: _________________ Construction / Extension Estimates] ___________________________ % complete: _______________ Exp. I / We am / are aware that the Original Title Deeds (including the Chain of Title) in respect of the Property standing in my / our name will have to be deposited to LICHFL as Security for the Loan. I / We agree that LICHFL may take up such references and make enquiries in respect of this Application.: - In Flat: - Const. Land / UDL Cost): _______________________ Estimated Cost for Const. In purchase cases. # _________________________ Ph.) REFERENCES Name: _____________________________________________________ Name: _____________________________________________________ Address: ___________________________________________________ Address: ___________________________________________________ ______________________________________ Dist.: ___________________ Validity (days) _____________ Improvement Please attach / detailed Renovation Estimates] Cost / Value of the Property (Rs. In case of Purchase of Plot or Ready-built / Under Construction House / In case of House Const.): Savings in Bank: ________________________________ Provident Fund (Refundable / Non-Refundable): __________________________________ Disposal of Investment / Property: ____________________________________ Loan from Employer: _____________________________________ Loan from LICHFL: ___________________________ Others: ____________________________ Total Funds: _____________________________ LIFE INSURANCE POLICY DETAILS Policy No. of Completion: ______________ Year _________________________________________________________ [Note: Please attach the case of of Improvement Construction of / the detailed House / Flat: ____________________________ Yr. as it may deem necessary from my / our Banker (s) or Employer (s) or Others. # _________________________ E-mail ID: __________________________________________________ E-mail ID: __________________________________________________ DECLARATION I / We declare that all the particulars and information given in the Application Form are True. Completion Dt. / Extn. Dt. # (O) ____________________ Mob. Applicant’s Signature : _______________________________________ Recent Passport-size Recent Passport-size Photograph of the Photograph of the Co- Applicant with applicant with Signature Signature across across Co-applicant’s Signature : _______________________________________ Place: ___________________________ Date: ____________________ Mail Correspondence to: Residence Address Office Address Permanent Address 3 .Do you propose to Rent out the Dwelling Unit? Yes No If yes.) Mode of Premium Pmt. I / We further agree that my / our Loan shall be governed by the Rules of LICHFL which may be in force from time to time. I / We undertake to inform LICHFL regarding any change in my / our Occupation / Employment and to provide any further information that you may require. Name of Insurer & Branch Name of Policyholder Type of Policy & Term Sum Assured (Rs. Rent Expected: Rs.: _____________ [Note: Sale Deed Dt. I / We understand that the Upfront Fee is not refundable under any circumstances. Stage (% completed): _________ Renovation: - Name & Address of Vendor / Builder / Society / Development Authority: Exp. # (O) ____________________ Mob.) Premium Amount (Rs. LICHFL may seek / receive information from any source / person to consider this Application. Correct. I / We also undertake to authorize my / our Employer (s) to deduct Equated Monthly Instalments from my / our Salary and remit the same to LICHFL directly every Month [Applicable only in Salary Deduction Cases]. ____________________/. ________________ State ______________________________ PIN State ______________________________ PIN STD Code ___________ Ph.): Cost of Land / Undiv. Share of Land (UDL): _________________________ Cost of Flat / House (excl. and Complete. / Extn. of Comm. LICHFL may make available any information contained in this Form and other Documents submitted to LICHFL and information pertaining to the Loan to any Institution or Body.: _______________________________ Estimated Cost for Improvement / Renovation: _______________________ Cost of Amenities: _________________________ Total Cost: __________________________ Value of Property: __________________________ Source of Funds (Rs. Present Surrender Value (Rs.m.p. I / We have understood and selected the Interest Rate Option available. [M / Q / H / Y] Dt. I / We are aware that the option on Interest Rate once selected cannot be changed and change (s) may be permitted only at the sole discretion of LICHFL on such Terms and Conditions as may be decided by LICHFL. and that they shall form the basis of the Contract for any Loan LICHFL decides to grant to me / us. ________________ ______________________________________ Dist.

etc. [Please attach separate sheet if space is insufficient] In case the Security is Life Insurance Policies [Please attach Surrender Value Quotations]. attach copies of Instruments] Certificate No. Name of the Certificate Denomination of Holder Certificate (Rs.) [Pl.) Premium Amt. of (Rs. Policy No.) Date of Issue Date of Maturity DECLARATION I / We am / are aware that the Original Life Insurance Policy Documents / Fixed Deposit Receipts of Nationalised Banks / Post Office Instruments after Assignment / Marking of Lien of LICHFL. KVP. Mode of Dt. as applicable.D. Term Pmt.) Commencement Date of Maturity In case the Security is Post Office Instruments (NSC.ADDENDUM TO APPLICATION UNDER GRIHA PRAKASH LOAN ENHANCEMENT UNDER NEW GRIHA LAXMI If Loan Enhancement is sought under New Griha Laxmi Scheme. [M / Present Surrender Value (Rs.O. No.) Q / H / Y] In case the Security is Fixed Deposits of Nationalised Banks [Please attach copies of FD Receipts] F. Name of Insurer & Name of Policyholder Branch Plan & Sum Assured (Rs. please provide details below. Name & Address of P. Name of the Bank & Branch Name of the Depositor Face value of the Date of FDR (Rs.) Premium Comm. standing in my / our name will also have to be deposited to LICHFL as Security for the Loan. Applicant’s Signature: _________________________________________ Co-applicant’s Signature: ____________________________________ 4 .

if any Initials .APPLICANT CO-APPLICANT Specimen Signature Surname Full Name First Name Middle Name Surname First Name Middle Name Please draw Route Map of the Property in the space provided below. Date of Visit Visited by Observation 5 Amount Paid. FOR OFFICE USE (To be completed by the Area Office) S. No.

S. No. if any Initials . Date of Visit Visited by Observation 6 Amount Paid.

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