APPLICATION FORM APPLICATION NUMBER PG NO.

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TYPE OF FACILITY

Product Type : Balance Transfer

LoanType : Home Loan
Name of the Financial Institute/ HFC/NBFC : HDFC BANK LTD
Pre approved Offer Available : NA

APPLICANT DETAILS

PERSONAL DETAILS

Name : Mrs Usha d

Mother's Name : Shanthi
Father's Name : A doreswamy
Spouse Name : Kiran kumar s
Gender : Female
Date of Birth : 02-11-1993
PAN : CBVPD9018H
Marital Status : Married
Number of Dependents : 1
Person with disabilities : No
Category : General
Religion : Hindu
Residency Status : RI
Current Residence : Owned
Qualification : NA

CURRENT/COMMUNICATION ADDRESS

Address 1 : 831/H 27TH CROSS 4TH MAIN

Address 2 : VIDYARANYAPURAM
Address 3 : MYSORE
Landmark : NA
District : Mysuru
State : Karnataka
State / UN Code : KA
City : Mysore
Pincode : 570008
Residing Since : 4 years -5 months
Mobile No : 9513026632
Email ID : usha.hsc@gmail.com
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PERMANENT / REGISTERED ADDRESS

Same as Current /Communication Address : No

Address 1 : 4/137
Address 2 : MATADA STREET
Address 3 : KOLLEGAL, CHAMARAJANAGAR
Landmark : NA
District : Chamrajnagar
State : Karnataka
State / UN Code : KA
City : Kollegala
Pincode : 571440

OCCUPATION/BUSINESS DETAILS

A) Salaried / Self Employed : Salaried

Company / Occupation Type : NA
Work Experience / No of years in business : 4 years

Customer Working On : NA

Company Name : Kptcl

Designation : ASSISTANT
Office Address 1 : Prasarana bhavana ground floor
Office Address 2 : FTS premises N R Mohalla
Office Address 3 : Mysore
Landmark : NA
City : MYSORE
State : KARNATAKA
State / UN Code : KA
Pin : 570007
Official Email ID : NA

B) Only for Self Employed

Profession : NA
Annual Sales Turn Over : NA
CIN No : NA
Date of Incorporation : NA

Preferred Mailing Address : Current/ Communication Address

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BANKING DETAILS

Do you have an ICICI Bank Account? : No

Account Type : NA
Account Number : NA

CONSENT FOR ICICI BANK

ICICI Bank Limited (“ICICI Bank”) would like to use your personal details in the application form/registration form from time to
time to send you marketing information to inform you about products, services or promotional offers that are offered by ICICI
Bank on its own and in collaboration or through tie-ups with partners/ third parties. By opting into the following methods of
communication, you confirm that ICICI Bank may contact you for these purposes in one or more of the following ways:

By Email, By SMS, By Telephone

CROSS SELL

I the Applicant/Co-Applicant hereby give my consent that I/we are interested to open an ICICI Bank Saving*/Current Account
(”SA” /”CA”), basis the information and KYC documents furnished by me/the co-applicant (”Applicant/s”) in ths ICICI Bank
home loan application form. I/We further give my / our express consent to ICICI Bank and its authorized personnel to contact
me /us in the person/phone/SMS/ e-mail with regards to opening of the SA/CA with ICICI Bank.

Savings Account
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FINANCIAL CO-APPLICANT DETAILS

PERSONAL DETAILS

Name : Mr. Kiran kumar s

Mother's Name : Sulochana
Father's Name : Somachar
Spouse Name : Usha d
Gender : Male
Date of Birth : 02-07-1988
PAN : FJUPS2725E
Marital Status : Married
Number of Dependents : 1
Person with disabilities : No
Category : General
Religion : Hindu
Residency Status : RI
Current Residence : Owned
Qualification : NA
Other Document Type : NA
Other Document Number : NA

CURRENT/COMMUNICATION ADDRESS

Address 1 : 831/H 27TH CROSS 4TH MAIN

Address 2 : VIDYARANYAPURAM
Address 3 : MYSORE
Landmark : NA
City : Mysore
District : Mysuru
State : Karnataka
State / UN Code : KA
Pincode : 570008
Residing Since : 5 years -6 months
Mobile No : 9513026632
Email ID : usha.hsc@gmail.com
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PERMANENT / REGISTERED ADDRESS

Same as Current /Communication Address : Yes

Address 1 : 4/137
Address 2 : MATADA STREET
Address 3 : KOLLEGAL, CHAMARAJANAGAR
Landmark : NA
District : Chamrajnagar
City : Kollegala
State : Karnataka
State / UN Code : KA
Pincode : 571440

OCCUPATION/BUSINESS DETAILS

A) Salaried / Self Employed : Salaried

Company / Occupation Type : NA

Work Experience / No of years in business : 13 years
Customer Working On : NA
Company Name : Wellesta healthcare pvt ltd
Designation : Business executive
Office Address 1 : Unit 3A level 2 the centrium phoenix
Office Address 2 : Market city complex LBS road
Office Address 3 : Kurla mumbai
Landmark : NA
City : MUMBAI

District : Mumbai

State : MAHARASHTRA
State / UN Code : MH
Pin : 400070
Official Email ID : NA

B) Only for Self Employed

Profession : NA
Annual Sales Turn Over : NA
CIN No : NA
Date of Incorporation : NA

Preferred Mailing Address : Current/ Communication Address

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BANKING DETAILS

Do you have an ICICI Bank Account? : No

Account Type : NA
Account Number : NA

CONSENT FOR ICICI BANK

ICICI Bank Limited (“ICICI Bank”) would like to use your personal details in the application form/registration form from time to
time to send you marketing information to inform you about products, services or promotional offers that are offered by ICICI
Bank on its own and in collaboration or through tie-ups with partners/ third parties. By opting into the following methods of
communication, you confirm that ICICI Bank may contact you for these purposes in one or more of the following ways:

By Email, By SMS, By Telephone

CROSS SELL

I the Applicant/Co-Applicant hereby give my consent that I/we are interested to open an ICICI Bank Saving*/Current Account
(”SA” /”CA”), basis the information and KYC documents furnished by me/the co-applicant (”Applicant/s”) in ths ICICI Bank
home loan application form. I/We further give my / our express consent to ICICI Bank and its authorized personnel to contact
me /us in the person/phone/SMS/ e-mail with regards to opening of the SA/CA with ICICI Bank.

Savings Account
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GENERAL DETAILS

ABOUT MY FACILITY REQUIREMENT

Loan Amount Requested : 10412000

Loan Tenure : 240
Type of Interest : Floating
Property Status : NA
Original loan amount sanctioned : NA
Outstanding loan amount : NA
Seasoning of loan : NA
Property value : NA
Base loan account number : NA

PROPERTY DETAILS(COLLATERAL)

Property Identified : Yes

Project Name : NA
APF No : NA
Address 1 : NO 831/H 27th cross 4th
Address 2 : Vidyaranyapuram mysore
Landmark : NA
City : MYSORE
District : Mysuru
PIN : 570008
State : KARNATAKA
Property Status : NA

PRIORITY SECTOR DECLARATION

Housing Declaration :
I/We agree and confirm that neither me / us, nor any of my/ our family members have availed/applied for Housing loan from
any bank/ financial institution for the purchase/ construction of my /our dwelling unit (”purpose”) NA

I/We confirm this is my/our first Housing loan NA

MSME Declaration :

NA NA

Udyog Aadhar : NA
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GST RELATED DETAILS

Are you registered for GST? : NA

GST Applicable Customer : NA
GSTIN : NA

FEE DETAILS

Payment Option : Single

Non-refundable processing fee : 3118

LOGIN FEE BALANCE FEE

Fee Amount : 3118 NA

Payment Date : 2021-12-16T12:47:19 NA
Type of payment : NA NA
Payment Mode : upi NA
Transaction ID : NA NA
PG Reference Number : 700113504124718 NA
Payment Status : Successful NA
Cheque Number : 0 NA
Bank Name : NA NA

The processing fee is a one-time non-refundable fee, and is collected by ICICI Bank for the purpose of appraising the
Application for the facility and the same is independent of the outcome / result of such appraisal.

REFERENCE

REFERENCE 1

Name : Santhosh Santhosh

Address 1 : NA
Address 2 : NA
Pincode : NA
Mobile No : 9738469467
Relationship with Reference : Friend
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REFERENCE 2

Name : Suresh Gajendra

Address 1 : NA
Address 2 : NA
Pincode : NA
Mobile No : 9845494449
Relationship with Reference : Friend

FOR OFFICE USE ONLY

SOURCING CHANNEL DETAILS

Channel Type : NA
Channel Name : NA
Broker Id/Branch Sol Id : 293092
BSM/ RM Emp Id : 200187
CRM ID : 527705338
Counsellor ID : 291319

ATTESTATION

I NA hereby confirm that I have seen the original KYC documents of the applicant/s and have verified the same.

KYC VERIFICATION CARRIED OUT

Emp.Code : NA
Emp.Name : NA
Emp.Designation : NA
Emp.Region : NA

OTHER DETAILS

Details Existing Customer Type of account Account number Video KYC

Primary Applicant No NA NA No
Co-applicant 1 No NA NA No
Co-applicant 2 NA NA NA No
Co-applicant 3 NA NA NA No
Co-applicant 4 NA NA NA No
Co-applicant 5 NA NA NA No
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DECLARATIONS

1. I/We hereby confirm my/our interest to apply for loan facility on the terms and conditions specified by ICICI Bank Limited
(“ICICI Bank”) on www.icicibank.com and as updated/modified from time to time.

2. I/We hereby confirm that I/we have authorized the representative of ICICI Bank to enter the application details in the
electronic application form on my/our behalf in accordance with the instructions/information given by me/us in the electronic
application form.
3. I/We have reviewed and verified the details entered by ICICI Bank’s representative in the electronic application form and
declare the same to be true, correct and updated. I/We hereby confirm that and the electronic application form has been
submitted by ICICI Bank’s representative post my/our review, verification and confirmation of the application details.

4. I/We confirm that the details provided in the electronic application form and the details already available with ICICI Bank
(if any) are true, correct, complete and up to date in all respects and that such details can be relied upon by ICICI Bank to
consider my/our request for loan facility.
5. I/We understand the electronic application form shall be final application form submitted by me/us for the purpose of
availing loan facility.
6. I/We have read, understood and hereby agree to terms and conditions applicable to my/our loan application set forth on
the website www.icicibank.com. I understand that access to any changes/updation in terms and conditions applicable to this
application would be available on the website only.

7. I/We further understand and acknowledge that ICICI Bank may procure any other information or verification that ICICI
Bank may have access to or that is otherwise available in the public domain and conduct such diligence / investigation, as
ICICI Bank may deem fit, for the purpose of the loan facility.

8. I/We hereby authorize ICICI Bank to collect information/personal data from me and other agencies including Unique
Identification authority of India (UIDAI) & Credit information companies (CICs) & record and repository wherein my/our data
may be available for the purpose of making the offers available to me

9. I/We understand that the processing fee once paid by me/us will not be refunded by ICICI Bank in any circumstances.
The processing fee is a one-time non-refundable fee and is collected by ICICI Bank for the purpose of processing your
home loan request.
10. I/We understand that issuance of the sanction letter shall be at the sole discretion of ICICI Bank and shall be subject to
its internal policy.
11. I/We understand that the disbursement of funds under the sanction letter accepted by me/us is subject to completion of
legal and technical analysis of the property to be mortgaged, to the satisfaction of ICICI Bank, wherein the title to the
property can be ascertained to be clear and marketable.

12. I/We hereby confirm that the there are no insolvency proceeding initiated against me/us nor I/we has ever been
adjudicated insolvent / bankrupt.

13. I/We authorize ICICI Bank / its group companies / its agents to make references and enquiries relevant to information in
this application form which ICICI Bank / its group companies / its agents consider necessary.

14. I/We undertake to inform ICICI Bank / its agents regarding the change in the residential addresses to provide any further
information that ICICI Bank may require.
15. I/We understand that certain particulars given by us are required for by the operational guidelines governing banking
companies.

16. I/We hereby agree and authorize ICICI Bank / its group companies to exchange, share or part with all the information,
data or document in relation to the application including but not limited to the credit repayment, history or any default, if any,
committed by the me/us to credit bureaus, agencies, statutory bodies.
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17. Save and except to the extent as disclosed by me/us in this application, I/We, as an applicant(s) represents that: no
director or a relative/near relation (as specified by RBI) of a director of a banking company (including ICICI Bank) or a
relative near relation (as specified by the RBI) of a senior officer of ICICI Bank (as specified by RBI) is a partner of the
applicant/s, a director, manager, employee of the applicant/s or of a subsidiary of the applicant/s or a subsidiary or the
holding company of the applicant(s), or a guarantor on behalf of / for / to the applicant/s, or holds substantial interest in the
applicant/s, or a subsidiary of the holding company of the applicant(s).

18. I/We understand and agree that ICICI Bank may provide the credit facility/ies mentioned herein only if permitted and if
approved in the manner specified or required by the Reserve Bank of India from time to time.

19. I/We further agree and understand that ICICI Bank reserves the right to reject this application without assigning any
reason (unless required by applicable law), and that ICICI Bank shall not be responsible / liable in any manner whatsoever
to the me/us for such rejection or any delay in notifying the me/us of such rejection and any costs, losses, damages or
expenses, or other consequences, caused by reason of such rejection, or any delay in notifying the me/us of such rejection,
of this application.

20. I/We undertake to upload and submit all necessary documents as specified by ICICI Bank for the purpose of applying for
loan facility. I/We further confirm that the documents uploaded by me/us along with the application are true and
genuine copies of the original documents and ICICI Bank can rely on the said documents for the purpose as specified in the
application form.

21. I/We acknowledge that ICICI Bank reserves the right to retain such documents submitted with this application and will
not return the same to the me/us.

22. I/We hereby declare and affirm that the I/we have not made any payments in cash.

23. I/We hereby authorizes ICICI Bank to exchange, share or part with all information/ data provided herein including
personal and business information with ICICI group companies/other institutions/ such other persons as may be necessary/
required for the purpose of, including but not limited to, marketing, cross selling of various products and services etc to
me/us, use or process the aforesaid information/data by such person/s, or furnishing of the processed information/ data/
products thereof to other Banks/Institutions/other persons as may be necessary, and we shall not hold ICICI Bank liable in
connection with the use of such information or otherwise.

Specific Consent (Applicable for NRI customers)

24. I/We hereby authorize ICICI Bank to share this application form and all other documents/details submitted by me/us with
its group companies/affiliates for appraising the facility and I/We agree to not hold ICICI Bank liable for such sharing. I/We
understand that such documents can be relied upon by such group companies/affiliates for offering loan/facility to me/ us
and I/We further agree to promptly submit and provide additional information or documents, as may be required by such
group companies/affiliates, for considering my/our request for availing loan/facility. I/We further understand that approval of
the loan/facility and disbursements thereunder by such group companies/affiliates, shall be at their sole discretion
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Consent for ICICI Bank

ICICI Bank Limited (“ICICI Bank”) would like to use your personal details in the application form/registration form from time
to time to send you marketing information to inform you about products, services or promotional offers that are offered by
ICICI Bank on its own and in collaboration or through tie-ups with partners/ third parties. By opting into the following
methods of communication, you confirm that ICICI Bank may contact you for these purposes in one or more of the following
ways:

By Post By E-mail By Social Media By SMS/Text

By Telephone/Call Yes to marketing by all of the above

No to marketing by all of the above

ICICI Bank would like to share your personal details in the application form/registration form with its group entities / partners
of ICICI Bank so that the group entities / partners of ICICI Bank may from time to time send you marketing information to
inform you about the products, services or promotional offers that are offered by the group entities / partners in collaboration
with ICICI Bank. By giving your preference below you either allow or disallow ICICI Bank to share your personal details in
the application form/registration page:
Yes, I would like ICICI Bank group companies to contact me
Yes, I would like Partners of ICICI Bank to contact me
No, I do not wish ICICI bank group companies and Partners of ICICI Bank to contact me.
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DESCRIPTION OF CHARGES

Facility Processing Charges 0.5%

0.5% --- 2%
0.5% 2% processing
2% processing fee
processing fee or
fee or 3,000
or 3,000 whichever
3,000 whichever is
whichever is higher.Fees
is higher.Fees are
higher.Fees are non
are non
non
refundable.
refundable.
refundable.
Nil for home loans ,Land loans and Home Improvement loans with
floating rate of interest.
2% plus applicable taxes on principal outstanding* on full repayment
for Home loans with fixed rate of interest
2% plus applicable taxes on principal outstanding* on full repayment
for Top up loan if the loan purpose is business.
4% plus applicable taxes on principal outstanding* where all the
Prepayment Charges (if, applicable) borrowers are Non-individuals or if the loan is with fixed rate of
interest.

*Current principal outstanding and all amounts tendered by the

borrower towards repayment of Facility during the last one year from
the date of final prepayment.
**Home equity loan/Home Equity Enhancement Loan, Office
Premises Loan Lease Rental Discounting Loan /Non Home Loan Top
up.

Charges for late payment/ additional interest

2% per month plus applicable taxes if any

Charges for changing from fixed to floating

rates of interest where Prepayment charges 1.75% on principal outstanding
are applicable
Charges for changing from floating to fixed
rates of interest where Prepayment charges 0.5 % on principal outstanding
are applicable
Charges for changing from floating to fixed
rates of interest with change in margin where
0.5 % on principal outstanding
Prepayment charges are applicable

Charges for changing rates of interest where

Prepayment charges are not applicable 1000
1000

Penal charges on land/plot Loan where

construction of the house is not completed
1%
within 2 years from the disbursement date

Charges Swap charges 500

Agreement Copy 500

Checque/ECS/AD bounce charges 500

CIBIL Report Charges 50 per applicant

Administrative charges
The administrative charges is collected by
the lender for the cost of carrying out
valuation,legal verification of property to 5000 or 0.25% on sanction amount which ever is lower
asertain suitability of acceptinng the property
for mortgage and is a non-refundable
charge.
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Charges for Duplicate No Objection 100

Certificate /No due certificate
Charges for revalidation og No Objection
100
Certificate

a For Registration of security created in favour of ICICI Bank:

1. When facility amount is equal to 5 lac or lesser:50

Non refundable charges levied by Central
Registry of Securization Asset
Reconstruction And Security Interest of
India.
2. When facility amount is greater than 5 lac or :100
b The charges for modification and satisfaction of security created in
favour of the Lender,if and when applicable , shall be levied as per
applicable law. For current charges and any revisions thereof, please
refer to the applicable rules, regulations,notifications etc,issued by
CERSAI.

Note : Goods and Service Tax and other govt. taxes , levies , etc. applicable as per the prevailing are will be charged over
and above these changes.
The above mentioned charges are subject to change . For the latest Home Loan charges ,please get in touch with ICICI
Bank representative.

For the detailsed Terms & Conditions governing facilities for /against properties , please visit to out website
www.icicibank.com or get in touch with ICICI Bank representative.

Date & Time : December 17 2021 09:17:51