Collecting Branch : EPS1 Servicing Branch : LIC of India, Vadodara City

4th Flr Baroda Co-Op. Bank Building

Transaction No : 6192912
Near Paradise Complex
Date ( Time ): 17/05/2020 ( 09:27:58 ) Vadodara,390005
bo_eps1@licindia.com
Receipt No : PR0619291200012021
HelpDesk: +91-022-1251

RENEWAL PREMIUM RECEIPT

Received with thanks ` 9,545.04 through Payment Gateway over the Internet from:

Smt./Ms./Shri : Patel Pritesh Kishankumar

towards the following :

Policy No Plan Inst. Premium No Of Inst Total Premium CGST Branch

Name Term Mode Due From Late Fee SGST/UTGST Next Due
Revival D.O.C. Sum Assured Due To CD Charges Total Amt Reg. No.
(Yes/No) (`) (`) (`)
874634991 836 9,335.00 1 9,335.00 105.02 876
Patel Pritesh 25 YLY 04/20 0.00 105.02 04/21
No 25/04/2016 04/20 0.00 9,545.04 24AAACL0582H2ZR
2,00,000

Page Total (`) 9,335.00 9,335.00 105.02

0.00 105.02
0.00 9,545.04
Grand Total (`) 9,335.00 9,335.00 105.02
0.00 105.02
0.00 9,545.04

NINE THOUSAND FIVE HUNDRED FORTY FIVE RUPEES AND FOUR PAISE ONLY

Patel Pritesh Kishankumar

Consolidated Stamp Duty Paid
I/202,2nd Floor,Viram -3
Maneja Jakatnaka CSD/323/2020/802/2020 DTD.20/02/2020
Vadodara

100000 Payment Acknowledgement generated through

Online Portal on 17-May-20 Time : 09:30:00.
Mobile: 7405329442
Email: ppritesh888@gmail.com

This receipt is electronically generated and no signature is required.

Har Pal Aapke Saath!