RTGS / Neft Account Verification & Payment instruction Slip

The Manager,

Bank Name -------------------------------------------------------------------------------

Branch Name ------------------------------------------------------------------------------
Location ------------------------------------------------------------------------------

I (Account holder name) residing at____________

_______________________________________________________________________________________

have applied for RTGS facility ( Real Time Gross Settlement ) of all disbursement transaction, hereby
authorize ICICI Bank to credit my account through RTGS for the same. As per the details give as under.

Account type Savings/ Current / Overdraft

Beneficiary details : _____________________________________

Beneficiary name : _____________________________________
Account number : _____________________________________
Location : _____________________________________
Bank name : _____________________________________
Branch address : _____________________________________
Account type : _____________________________________
MICR code : _____________________________________
IFSC code : _____________________________________

Remarks/Narration

I hereby declare that the particulars given above are correct and complete. If the transaction is delayed or
not effected at all for reasons of incorrect or incomplete information, I will not hold the user institution
responsible. I have read the option invitation letter and agree to discharge the responsibility expected of me
as a participant under the scheme.

(..............................)(................................)(..............................)(..............................)

Date :

Signature of authorized official of Bank