APPLICATION FORM APPLICATION NUMBER PG NO.

7723482646 1/13

TYPE OF FACILITY

Product Type : Home Loan

LoanType : Composite Loan (Plot + Construction)
Name of the Financial Institute/ HFC/NBFC : NA
Pre approved Offer Available : NA

APPLICANT DETAILS

PERSONAL DETAILS

Name : Mr Hemalatha rajeshkumar

Mother's Name : Navamani j
Father's Name : Jaghanaathan palaniyappan
Spouse Name : Rajesh kumar
Gender : Female
Date of Birth : 08-07-1985
PAN : AJKPJ0979L
Marital Status : Married
Number of Dependents : 1
Person with disabilities : No
Category : General
Religion : Hindu
Residency Status : RI
Current Residence : Owned
Qualification : Graduate

CURRENT/COMMUNICATION ADDRESS

Address 1 : PLOT NO 95 , LILLY FLAT

Address 2 : SUBBIAH NAGAR
Address 3 : SSD OIL MILL RD
Landmark : NA
District : Kanchipuram
State : Tamil nadu
State / UN Code : TN
City : Chennai
Pincode : 600056
Residing Since : 08 years -00 months
Mobile No : 9789051170
Email ID : HEMAS886@GMAIL.COM
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PERMANENT / REGISTERED ADDRESS

Same as Current /Communication Address : Yes

Address 1 : PLOT NO 95 , LILLY FLAT

Address 2 : SUBBIAH NAGAR
Address 3 : SSD OIL MILL RD
Landmark : NA
District : Kanchipuram
State : Tamil nadu
State / UN Code : TN
City : Chennai
Pincode : 600056

OCCUPATION/BUSINESS DETAILS

A) Salaried / Self Employed : Salaried

Company / Occupation Type : NA
Work Experience / No of years in business : 14 years

Company Name : Tata consultancy services

Designation : ASSISTANT CONSULTANT
Office Address 1 : TATA CONSULTANCY SERVICES
Office Address 2 : SIPCOT IT PARK
Office Address 3 : SIRUSERI
Landmark : NA
City : CHENNAI
State : TAMIL NADU
State / UN Code : TN
Pin : 603103
Official Email ID : hema.jaga@tcs.com

B) Only for Self Employed

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

Preferred Mailing Address : Current/ Communication

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BANKING DETAILS

Do you have an ICICI Bank Account? : No

Account Type : Others
Account Number : NA

PMAY Eligibility

Customer Prompted for PMAY : NA

Annual Family Income : NA
Customers 1st Pucca house : NA
Women Owner / Co Owner : NA
Female Member in Customer's Family : NA
Eligibility Status : NA
Primary Applicant Name as per Aadhar : NA
Is Name on Aadhar same as PAN : 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 all options : By Email, By Post, By SMS, By Social Media, 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.

NA
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FINANCIAL CO-APPLICANT DETAILS

PERSONAL DETAILS

Name : Mr. Raja rajesh kumar

Mother's Name : Krishnaveni r
Father's Name : Raja
Spouse Name : Hemalatha
Gender : Male
Date of Birth : 19-03-1984
PAN : ALBPR6221Q
Marital Status : Married
Number of Dependents : 1
Person with disabilities : No
Category : General
Religion : Hindu
Residency Status : RI
Current Residence : Owned
Qualification : PG
Other Document Type : NA
Other Document Number : NA

CURRENT/COMMUNICATION ADDRESS

Address 1 : PLOT NO 95 , LILLY FLAT

Address 2 : SUBBIAH NAGAR
Address 3 : SSD OIL MILL RD
Landmark : NA
City : Chennai
District : Kanchipuram
State : Tamil nadu
State / UN Code : TN
Pincode : 600056
Residing Since : 08 years -00 months
Mobile No : 9884567060
Email ID : RAJESHRAJACHENNAI@GMAIL.COM
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PERMANENT / REGISTERED ADDRESS

Same as Current /Communication Address : Yes

Address 1 : PLOT NO 95 , LILLY FLAT
Address 2 : SUBBIAH NAGAR
Address 3 : SSD OIL MILL RD
Landmark : NA
District : Kanchipuram
City : Chennai
State : Tamil nadu
State / UN Code : TN
Pincode : 600056

OCCUPATION/BUSINESS DETAILS

A) Salaried / Self Employed : Salaried

Company / Occupation Type : NA

Work Experience / No of years in business : 15 years
Company Name : Hdfc sales private limited
Designation : AREA MANAGER
Office Address 1 : HDFC SALES PRIVATE LIMITED
Office Address 2 : No . 321/1A , MOTI TOWERS
Office Address 3 : 3 RD FLOOR , OMR , PERUNGUDI
Landmark : OPP TO APOLLO HOSPITAL
City : CHENNAI

City : Kanchipuram

State : TAMIL NADU

State / UN Code : TN
Pin : 600096
Official Email ID : rajeshkumarr@hdfcsales.com

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 all options : By Email, By Post, By SMS, By Social Media, 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.

NA
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GENERAL DETAILS

ABOUT MY FACILITY REQUIREMENT

Loan Amount Requested : 4000000

Loan Tenure : 180
Type of Interest : Floating

PROPERTY DETAILS(COLLATERAL)

Property Identified : Yes

Project Name : NA
APF No : NA
Address 1 : GLOBUS FORTUNE
Address 2 : PADUR
Landmark : NA
City : CHENNAI
District : Kanchipuram
PIN : 603103
State : TAMIL NADU
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”) No

I/We confirm this is my/our first Housing loan No

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 : 3000

LOGIN FEE BALANCE FEE

Fee Amount : 3000 NA

Payment Date : 2021-01-25 NA
Type of payment : Cheque NA
Payment Mode : Offline NA
Transaction ID : NA NA
PG Reference Number : 100000097602 NA
Payment Status : Subject To Realization NA
Cheque Number : 072921 NA
Bank Name : ICICI BANK LTD 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 : Sridhar S
Address 1 : Plot no 95 , lilly flat , 1st floor
Address 2 : subbiah nagar , ayyapanthangal
Pincode : 600056
Mobile No : 9962944759
Relationship with Reference : Friend
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REFERENCE 2

Name : MOHANASELVI R
Address 1 : DOOR NO 340
Address 2 : A.P.T ROAD , ERODE
Pincode : 638004
Mobile No : 9942552928
Relationship with Reference : Friend

FOR OFFICE USE ONLY

SOURCING CHANNEL DETAILS

Channel Type : Counselor

Channel Name : Kingsley
Broker Id/Branch Sol Id : 266654
BSM/ RM Emp Id : 199549
CRM ID : 416744985
Counsellor ID : 226763

ATTESTATION

I Kingsley 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 : 266654
Emp.Name : Kingsley
Emp.Designation : Sales Representative
Emp.Region : Tamilnadu

OTHER DETAILS

Details Existing Customer Type of account Account number Video KYC

Primary Applicant No Others 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)

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.
 APPLICATION FORM APPLICATION NUMBER PG NO.
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DESCRIPTION OF CHARGES

0.5%
0.5% -- 2%
2% processing
processing fee
fee or
or 3,000
3,000 whichever
whichever is
is higher.Fees
higher.Fees are
are non
non
Facility Processing Charges
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

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 : January 27 2021 12:37:18