Collecting Branch : EPS1 Servicing Branch : 58H

E-mail : bo_eps1@licindia.com LIC of India, Bhubaneswar Br Office-2

Phone : +91-022-1251 STOCK EXCHANGE BUILDING
P-2, JAYADEV VIHAR, CHANDRASEKHARPUR
Transaction No. : PR0600023600011617 CHANDRASEKHARPUR
Bhubaneshwar Ii
Date ( Time ): 18/08/2016 ( 14:19:13 ) Orissa 751023

RENEWAL PREMIUM ACKNOWLEDGEMENT

Received with thanks Rs. 21701.00 through Payment Gateway over the Internet from:

Smt./Ms./Shri : Srinibas Mohanty

Towards the following

Policy No Plan Inst. Prem(Rs) No Of Inst Total Premium Service Tax Branch
Name Term Mode Due Fr Late Fee Edu Cess Next Due
Agency Code D.O.C. Sum Assured Due To CD Charges Total Amt
574885268 814 21,302.00 1 21,302.00 399.00 58H
Mohanty S 18 HLY 08/16 0.00 0.00 02/17
0221658H 18/08/2014 7,50,000.00 08/16 0.00 21,701.00
Page Total (Rs) 21,302.00 21,302.00 399.00
0.00 0.00
0.00 21,701.00
Grand Total (Rs) 21,302.00 21,302.00 399.00
0.00 0.00
0.00 21,701.00

RUPEES TWENTY-ONE THOUSAND SEVEN HUNDRED ONE ONLY

Srinibas Mohanty Payment Acknowledgement generated through Online

Samanta Sahi, New Colony Portal on 23-Jan-2017 Time : 11:09:18.
Buxi Bazar
Cuttack
753001

This receipt is electronically generated.

Zindagi Ke Saath Bhi, Zindagi Ke Baad Bhi

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