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Brokers Name: ICICI Bank Intern et BankingI C I C IHomeFinanceCompany Limited

Regd.Office:ICIC IBa nk T o w e r s, Code No. C121101Bandra-KurlaComplex,Mumbai400 051 Sub Broker Code:Tel.: (022) 2653 1414 Fax: (022) 2653 1671 Branch SOL ID:

(To be singed across the photograph)

Customer ID No Appl No SR126638000 Br Code

Brokers are not permitted to accept cash with the Application Form. Brokers are not permitted to issue a receipt.The Company will in no way be responsible for such or other wrong tenders.

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Affix a latest photograph here

Application Form for deposit values

Name of depositor/s (In block letters) 2. Date of birth 04/08/1987

Sole/First Mr/ Mrs/ Ms MANEPALLI For 1st depositor (Compulsory)

Nationality : ____________________________________________________________________ Income-Tax Permanent Account Number (PAN) (Attach a copy of PAN card)Proof of Identity to be provided by Applicant ( Please submit copy of ANY ONE of the following self-attested documents)

Passport PAN Card Driving License Voters Identity Card

Photo Debit Card issued by any Scheduled Commercial Bank Any other Identification proof with Photograph(Subject to satisfaction of ICICI Home Finance)

Please specify______________________________

3. A D D R E S SOFSOLE/FIRSTD E P O S I TO R (IN BLO CKLETT ERS) (for all future communication)

S/O RAMESH RAJAHMJJKJ JHKLJKLJKL KAKINADAPin: 533293 TelRes: Off: Fax:Mobile: 9022810660 Email: venkatesh@yahoo.com

Proof of Address to be provided by Applicant ( Please submit copy of ANY ONE of the following self-attested documents) Latest

Utility Bill Latest Bank Account Statement Registered Rent Agreement

Ration Card Any other Address Proof ( Subject to satisfaction of ICICIHome Finance)Please Specify

4. DE PO SITSC HE M E

I/We applyfor placement/renewalof fixed deposit for Amt 10000 .Period:30 Months Months @ % per annumin the followingIncomePlan fothe deposit made on 10/12/2009Cum ulative(Annualized Yieldon Maturity) Non cumulative Annual Income Plan a) Yearly B) Quarterly C) Monthly

5. C A T E G O R Y

Shareholder Director/Relativeof Director Promoter Public

7. T A XSTATUS

Tax to be exempted: No

If yes, proof submitted Yes No

Form 15H 15GAnyother Tax Exemption

Certificate (For 65 years of age and above)

Fo lio No. of any other IC ICI Home Finance FD(s):

6. D E TA I L SOFBANKACC OUN T(of sole/first depositor)

(Pleaserefer to the clause on Interest Payments)Savings Current

Account No .041101506148

Bank ICICI Bank

Branch

9 DigitCode No.(As appearing on M I C R cheque issued by your bank)

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