Application for Funds Transfer through RTGS/ NEFT

cCI Bank ORTGSONEFT (Select RTGS or NEFT as remittance type)

To/M,
The Branch Manger/ TrAT Uáyas
Branch/ TRAT
Dear Sir/ a HEiqa,
Date/arte: D DM M
Please remit through NEFT/ RTGS a sum of Rupees in words)
only as per details give belovw:
(TET )

Cashlonly for NEFT)Y/44=7 ( 7 yHdyne) à fag}* Cheque Debit of my/our account (only for NEFT)
In case of cash please fil in the pay-in-slip/ FrI 7acifarary ù-za-fy à
To be filled by the Applicant in CAPITAL LETTERS/v ftem de à t

DETAILS OF APPLICANT (REMITTER)>TA4n /us feer

Account Number/*TI HRT
The Legal Entity ldentifier (LEI) (20-digit number):
Validity date of the LEI Number (Date should have a validity for subsequent fortnight) Date/ D| DM
I Y
Note: The LEl mentioned ontheslipmust be matching with the LEl submitted and recorded by the customer with the Bank
either at the account opening stage or subsequent stages.
Applicable for all payment transactions of value z50 crore and above for NON individual customer
Cheque Date/
Cheque Number/ a R
Remitters Name/

Address/TAT:

Mobile/Other Number/

DETAILS OF BENEFICIARY/TATd T faaro

Beneficiary's Name/

Account Number/
ATHTT 351ETT TT:
The Legal Entity ldentifier (LEI) 120-digit number): T

For all payment transactions of value 750 crore and above for NON individual customer)

Bank Name/ 4 f4 aa 1

IFSC Code (11-digit)/

3ATYYErEN rE (11 )
Branch Address/

Confirm Account Number

Again/5I T: FAI *ar fae:

Remarks (if anyl/ feut (fa a):

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 PURPOSE cODE FOR RTGS/31Tdsye foy t T E

Cash Management Transfer/

INTE Interest/4TT SUPP Supplier Payment
CASH

CORT
Trade Settlement Payment/ LOAN Loan / U TAXS Tax Payment/ TT

DIVI Dividend/THiRT PENS Pension Payment/ TRAD Trade /TYTR

Government Payment / Salary Payment/

GOVT SALA TREA Treasury Payment/èstt PTIT
HEDG Hedging/e SECU Securities/ ufaqa VATX Value Added Tax Payment/

INTC
Intra Company Payment/ SSBE Social Security Benefit WHLD With Holding/

Terms and Conditions/f44 3iR FTd

This transfer is required for a single transaction/ae gT d7 ya êraa à Ay
The fund transfer will be governed by the terms and conditions given on our websitewww.icicibank.com/e at s t Tt ksgE www.icicibank.comw f

1/We authorise ICICI Bank to recover charges as may be applicable by debiting my account as mentioned above/ 3/g artatts tes si g eq * Ag sfige

1/We understand that as per the RBI circular dated October 14, 2010, transfer of funds through electronic mode wll be executed only onthebasis
of the account number of the beneficiary provided while initiating the transaction; name will not be considered as a criteria for providing credit.

understand that this facility is available only at select locations and banks covered under Electronic Funds Transfer facility offered by RB1 / z

the lCICl Bank RTGS acility

RTGS Payment Instruction, the Customer agrees and acknowledges that this RTGS Payment Instruction and
is Signin9toonthethis
Bysubject Terms and Conditions, the Notice and these terms, and requests the execution oftheseinstructions in terms thereo aei

Terms used but not defined herein shall have the meaning ascribed to therm in the Terms and Conditions/ a gT RT d t wiseeftetRa wa , I

The Customerunderstands that the terms enumerated in this RTGS Payment Instruction are in addition to and not in derogetion of the Terms and

Subject to ICICI Bank's right, at its sole discretion, to accept or reject the RTGS Payment Instructions, ICICI Bank shall endeavor to duly execute these

instructions, except when, inter alia, this RTGs Paymentinstructionis incomplete orhasbeenfilled in wrongly orthe instructonserena t e
executed under the RTGS. An acknowledgement of receipt of this RTGS Payment Instruction shall not be construed as binding ICICI Bank to execute
the same, other than in terms of the Terms and Conditions /réstye qra fAa zkR 1 37ETATR R oat: 3TÉeiTÉeN aITÉ T% 31frer HêagTREITYE HTATa A~a T/TT

ICICi Bank has not made any warranty and makes no representation about the quality, nature or availability of the ICICI Bank RTGS Facility/31Teha1Ts4t34T6

ICICI Bank shall have no obligations to any person including any beneficiary (or any person claiming under or through such beneficiary) other than the
Customer for the execution of this RTGS Payment Instruction/31Ttt s7TEhAT d 1 gE 3TRTsTZE TT FA}K G fAa fTY T r 1 I Aei sî anaeff ( qà arTef TEa qrm

The Customer is hereby notified that there is a risk of non - payment to the beneficiary on the day of the transaction. The same may be for any reason
ga holiday at the beneficiary's branch. ICici Bank or RBl or any other participant in NEFT/ RTGS shall not be liable, in any manner
whatsoever, inc
whatsoever, to the Customer for any such delay/Tgs ETaA t7 IT a-444tai AT41 5 PaT 7T ,TfE 1 PRaHI 3, aTNTT aTEIÀ YS anAT

For NEFT: Transfer of an amount up to 49,999/- in cash is permissible using this facility. KYC to be provided by non customer. Cheque is mandatory
for remittance above100,000/-./za zaT 374 76R49,999/-Ta I74iRi 5 FATAR *1ITdE 1RTES ZRIKYCeAfA 1 ATYU5 R100,000/-À 3 r i r 7 f a fATI

Customer Signature (S\/TE EKnaT

Signaturei1 Signature/1ER

Name/
Name:H Neme:T
(Primary Applicant)/A129ftcs 4Td47 (Joint Applicant 1/Eya HTdz 1) (Joint Applicant 2/ya c e 2)
For Bank Use Only

1. Sign and Employee ID (Maker):

2. Sign and Employee ID (Checker)
3. UTR/PIO Number
4. Transaction ID:
*******************************************************************************************.**************s********* ******************************************************** www ******************************

Customer Acknowledgement/WE6 THtG

Customer name / Date: D
Mode of payment/
Beneficiary name

Beneficiary bank name/

Beneficiary account

Transaction reference
number /tGH ÅAT: Amount/TH:
Bank Seal
Name and signature of Bank official /Te 31eR AH R zHR: