'ANNEXURE 1"

APPLICATION FORM FOR EMPANELMENT OF MARKETING INTERMEDIARY

To.

The Area Manager

LICHousing Finance Ltd.,
VIRARu) Office
Sir/Madam,
Sub: APPLICATION FOR EMPANELEMENT AS MARKETING INTERMEDIARY DIRECT
SELLING AGENT (DSAY HOME LOAN AGENT (HLA) | CUSTOMER RELATION
ASSOCIATE (CRA) / CORPORATE AGENTS / OTHERS (ANY OTHER CATEGORY OE
AGENTS INTRODUCED BY THECOMPANY)I WITH LIC HOUSING FINANCE LTD,
Isubmit herewith my application for the empanelment as 'Marketing Intermediary [Direct
Selling Agent (DSA) Home Loan Agent (HLA) / Customer Relation AsSociate (CRA) /Others
for LIC Housing Finance Ltd., I have read the terms and conditions relating to the service and
lundertalke that those are acceptable to me.

Fullname (in block letters) / SURESH SAHADEV JADHAV

Firm-mention name of the
firm
Name of key person (in case SURESH SAHADEV JA DHAV
of firm)
3 Father's/Husband's name SAHAVET JA DHAV
A Constitution Indiviual Proprietorship Partnership Company
(tick appropriate option)
Date of birth / incepOFaton
6
(DD/MM/YYYY) 15/03/i942
Age Years Months
7
Business / CommunicationoICE NO TI, NEW BNITA
Address PpNCHpL PGPR, NLLAOPA2A
8 Telephone number (Office): 986/40 432, 766 428626
(Residence):
Mobile number 98671o 432
10 Altermate Contact number 9 766728626
11 PAN Card no.
12 Aadhar Card No.(in case of AFTPI6T4M578|
8744 2089
individual) /Registration No.
in case of firm.
13 Present Occupation LIC AGENT
14 No. of years employment
/Business
 15| In case of firm- Do you have
an Office? If yes, number of
employees on roll
16 No. of Clients in
your
database:
a) Individual Clients 750 CLIENTS
b) Corporate Clierts
(give list separately)
17 Qualification
18 Language Known MARATHI
19 Details of past experience in
retail marketing (housing
Boans) VES
a. Bank
Name/ Others:
of lnstution/eo-BAnkfAz BeBo LC ot
b. Nature of product
marketed
C. Period of such work LiteIs peicieg
undertaken
d. No. of cases
Accounts procured 460 +
e. Quantum of
business (amt
1otocR.
involved)
f. Whether the activity
is continsing y ES
20 Give your brief Business
Plan /Strategy for marketing
housing loans
21 Expected annual business fer menth
with LICHFL
22 Reference 1.
(Name, Address & Contact DEEPA nISAL Nallaspaa luf q632445
number) 2.
BANJAy ktAOYE-NALLAscP 2A 2849141)

Ideclare that the statements in this application and the documents submitted (as per list given
that
below) are true, complete and correct to the best of my knowledge and belief. Ideclare,
no criminal proceedings are pending against me. I further deciare that i am not related to any
existing employee of LIC Housing Finance Limited. Iunderstand that in the event of any
information/document being found untrue / incorrect at any stage, my application is liable to
terminated.
be rejected and if already empanelled, the empanelment is liable to be

ALASOPARA w) Signature:
Place: N
Date:
B4<o242o23 Name: uRESH 8-JADHV
INCOME TAX DEPARTMENT GOVT. OF INDIA

SURESH S JADHAV

SAHADEV DEO JADHAV

15/03/1972
Permanent AccOunt Number
AFPPJ1614M

Signature

MANISH
SHARMA

ID-1071
AREA
MANAGER
LICHFL-VIRAR
A.0.
 31TET

aiauadantifieatian Authorit ofndia

Government ot india
1104/20613/02198
ateavaI H0E / Enrollment No
To,
Suresh Sahadev Jadhav
30/10/2012
DI1 19, Ruchita Apartments
Slation Road
Axis Bak Nalasopara West
Sopara
Sopara Thane Mumbai
Maharashtra 401203
9867170432

Ref: 2231 / 13 592502 592865LP

UE698639485/N

Aadhaar No. :
3J4GT 3TETT D6 / Your
8777 2089 5781

GOVERNMENT OEINDA

Suresh Sahadev Jadhav

gu Year of Birth:1972
T24/ Male

8777 2089 5781

 CIN: U40109MH2005SGC153645
SH F'o Nt: 3-245)4

BIL NO 0G4. BILL OF SUPPLY FOR THE MONTH OF -

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:001684482811
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10-12-2022
NEHAL SURESH JADHAV &
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APT.PANCHAL.NAGAR;NSPW]: 401203 30-12-2022
750.00

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axis
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DELIVERING TRUST
SINCE 1998
India's No. 1 Consumer Data Intelligence Company.
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SNO(GGN) 000001889650931 07-02-2023

ARI SURESH:001681442142 ldgt/a :97xx**xx26 161) 00

SAHADEV
D-11E RUCHITA APPT JADHAV WEST NILEMORE 401203
STN RDNALASOPARA 27-02-2023
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Premises
with BHIM Agp for
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:3/06/2027/0280/4157211
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[email protected]

For
:Advt.

India's No. 1 Consumer Data Intelligence Company.

axis' DELIVERING TRUST
SINCE 1998 www.axismyindia.org
MY INDIA

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GIRT HAR NUH 27-02-2023
 KYC| Know Your Customer (KY) Applcatlon Form Individual
Important Instructlons: Motor Vehche Act 199 is avatabie al lhe erd.
A)Fietds marked ith are mandalory fieBds. E) List of Slale /U.T code as per lndan
available at the end
8)Please fl the form in English and in BL0CK lellers F)Lisl of lwo chatacler 1803166 countr codes is
applicaton.
C) Plegce fl the datein D0-MM-YYYY formal G) KYC number of enplicant is mandalory tor updare LIC HI
D) Please read se chonwise delailed quidelines /inslnuelins H)For panictar sechion update. please tek() in the box tvailabie beiore t
updated.
reuitod to be
at the end sathon number and stnke off the se clionsrot

For office use onty Applicaton Type* New DUpdate

(To be fled by finanial insbBution)
KYC Number
Normal DSimplified (for low rsk customers)
DSmal
Account Type

U1. PERSONAL DETAILS (Please refer nstructon Aat the end) Middla NAmo
Prefix First Neme ADHAVI
Name (Same as ID proof) R SuIESIH
Maiden Name (If any)
Father Spouse Name" URIS SINEIHIAI UIESIHL
Mother Name MIRSI SIHIAGHI SIAIHGUEVL
Date of Birth 5-03-192 PHOTO
DF-Female OT-Transgender
Gender Male
DUnmarled DOthers
Marital Status* Maried
Others (ISO 3166 Country Code)
Citizenship IN-Indian
Non Resident India
Residential Status* Resident Individual O
Person of Indian Origin
DForeign Naional
U
SSevice (0Private Sector Public Sector DGovernment Sector)
Occupation Type Self Employed Retired DHousewife Jstudent
0-Others (Professiona!
O BBusiness
DXNot Categorised Dealers
Dealers DDealers in Arms LDBulion
Others (Aaase tick vhe avrisappicable) DAntique as money exchangers DExports/lmports Acivity. o
UConducting Money Service Bureau such
Exposed Person
OReal Estate &Constuction Business DPoliticaly
Less than Rs5 Crore
DRs. 5 Crore or More
Networth (Assets-Liabifbes)
refer instrucion Bat the end)
2 TICKIF APPLICABLE RESIDENGE FOR TAX PURPOSES IN JURISDICTION(S) OUTSIDE INDIA(Please
ADDITIONAL DETAILS REQUIRED" (Manadatory only if section 2 is ticked)
ISO 3166 Country Code of Jurisdiction of Residence*
Tax ldentification Number or equivalent (If issued by jurisdiction)*
ISO 3166 Country Code of Birth
Place / City of Birth MumS HTII
D3. PROOF OFIDENTITY (Pol) (Please reter instruction Cat the end)
needs to be submitted)
Certiied copy of any one of the following Proof of ldentityPol] O-0-TO
Passport Expiry Date
A- Passport Number
I8-Voter ID Card
P C-PANCard HPPITH614 -HI
Driving Licence Expiry Date
D-Driving Licence
E-UID (Aadhaar)
F-NREGA Job Card
Z-Others (any document notified by the central government) I I identification Number
Ssimpltied Measures Account- Document Type code ldentification Number

4. PROOFOF ADDRESS(PoA)
DETAILS (Please see InstructionDat the end)
D41CURRENT PERMANENT / OVERSEAS ADDRESS
Address PoA] needs to be submitted)
(Certiied copy of any one of the folBoing Proof of
DResidential / Business DResidential \ZBusiness O
Registered Office DUnspecifed
Address Type
Proof of Address" OPassport O
Driving Licence ZUD (Aadhaar)
DVoter ldentity Card DNREGA Job Card DOthers
DSimplified Measures Account - Document Type code I
Address SIICHSIZ
Line 1* DIPI2TCULNIO NAW AL IALoPIAA e
Line 2 PIAINCHAL NAGAK City / Town / Village*
Line 3 Country Code* Pin /Post Code ZAl//291
District PIALKIHCHKIIState /UT Code'
D42cnDDESDONDENCE
nSame Rt
LOCALADDRESS ETAS(th thresie f M)
Cuent /Permanent /Overeees Arldrees
delalle (In ceeo f rniite
corrbtea
line 3
I50 3144 ontr Coge

D43ADDRESS 0N THE JURISDICTION DETALS WHERE

APPLICANT IS RESIDENT
DSame As CUTent /Permanenl /Overseas Address dehails
Line 1
Line 2
Line 3
Stale ZIP/PostCode' T O ISO 3165 Courtry Cede

u6.CONTACT DETAILS (All Communcations I he set on roudeM hle no /Emeb (Pleese teter InstrucSon Fatte erdy
Tel. ( O m ) I O I Tel. (Res) Mobie -a6 to32
FAX
EnallD
JJahav 6 820 mdil(o m
a.DETALS OF RELATED PERSON (Ih caseaf ad4hianal related pereone, please #'AmenreBr) (pleose reler instrueton G the end)
Addition of Related Person Delelion of Related Person KYC Nunber of Relaled Person (f avaitabie")
Related Person Type" OGuardian of Minor O
Assignee D Authoized Representative
Prefix First Name Mode Name Last Name
Name
( KYC number and name are proióed, below delails of secfion 6 are opional)
PROOF OF IDENTITY Poll OF RELATED PERSON (Please see instrucion (M) t the end)

A- Passport NumberI Passport Expiry Date

E i e r 10 Card
C- PAN Card
D- Driving Licence Driving Licence Expiry Date -O-0D
E- UID (Aadhaar)
F- NREGA Job Card
Z-Others (any document notiied by the central govemment) ldentification Number
SSimplifed Measures Account- Document Type code ldentification Number

O7.REMARKS(If any)

8. APPLICANT DECLARATION
Ihereby dedare thal the details fumished above ars true and corect lo the best of my kncvledge and betief andlunder lake to infom you of any
Changes therein, immediately. In case any of the above infommaion is found to be false or unue or miseading or misrepresenßng, Iem eware
that Imay tbe heid liable forit

Date:-0-0O Place: Signahre / Thunb Inpresson ot Acgicant

9. ATESTATION / FOR OFFICE USE ONLY
Documents Recelyed DCerttied Copies
KYC VERIFICATION CARRIED OUT BY INSTITUTION DETAL S

Date
Name
Emp. Name
Emp.Code Code
Emp. Designation
Emp. Branch

2
3/4/23, 12:53 PM Mail - Manish Sharma - Outlook IATYHE|
Branch
Head

C52
. rs

BANK

AXIS

NR NniD
t.iun
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RD
sTN

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KUCHIA

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 Initiats

Balance
Withdrawals
Deposits
Date Particulars Cha No.

19-02-23 UPI/34oO1360/Vi 20.0G

shal SiLara Yadav
0-02-23 U"I/341i45709465/ SA
)SIH,V)Dr 3HWAR JHA 3061. G0C1
20-02-23 IMPS/S0ST12193104/A 50.00
PNA SfAK/ASBL/XX06 3OS?.Z20r
20 02-23 CHRG/IPS/3051121.93 I.13

i04/AFNA SAFIAK/ASBL. 3000. 00

5?.22Ci
O02-23 UPi/341767817562/SA
LIL EKHATH RANE 1115. G0
174.220:
02-23 UPI/305189554499/NA
RVEKAR SURAJ ONYNES 645.82Cr
529.00
2O-02-23 UPI/305194916401/SA
LIL EKNATH RANE 615.82Cr
i-02-23 UP0/305299547095/10 30.00
00211215000002.9881

nltials|

318U

Chq No. Withdrawals Deposits Balance

Date Particulars

600.00 l5.32Cr
41-02-23 UPI/341806147305/%i
rpa Printing House
41-02-23 UPI/30521. 4845309/ GA 400.00 415,82Cr
iNESH VASENT EURTE
4-02-23 UPI/Z41824451547/Ki 400.00 15.82Cr
I pa Prhirting House
02-23 JPI/3053311933S3/AK 3540.00 3555.32Ci
SHATA f!4NT FPEEKAR
42 02-23 custrnet/tilALASDPAFRA 3500.00 55.82CI
43-02-23 UPI/305447614981/4H 3070.00 3125. 82Ci
Ai!DU 0NUAUEV PHALL
43-02-23 ID0s62))/23-02-23 L 3000,00 l25.82Cr
3:03:47 /0000005591
43-02-23 UPI/39544292446/In l0.00) 15.82Cr
dian fRiil way | icke
Acknowledgement Number:879545730291222 Date of filing : 29-Dec-2022

INDIAN INCOME TAX RETURN ACKNOWLEDGEMENT Assessment Year

|\Where the data of the Return of in Forn ITR-1(SA|AJ), ITR--2, ITR-3, ITR-4(SUGAM),
ITR-5, ITR-6, ITR-7
Income filed and verificd]
2022-23
(Please sce Rule 12 of the Income-tax Rulcs, 1962)
PAN
AFPPM614M
Name SURESH SAHADEV JADIIAV
STATION ROAD,NALLASOPARA (W) .
Address MALRUCHITA APARTMENT,BEHIND BABLY APARTMENT.
NALLASOPARA, PALGHAR , 19-Maharaslhtra , 91-India , 401203
ITR-4
Status Individual Form Number
879545730291222
Filed us 139(4)Bclatcd- Rcturn filed afler duc datc c-Filing Acknowledgement Nurnber

Current Ycar business loss, if any

cdetails
Tax
nd
Total Incone 4,69.710

Book Profit under MAT, wherc 2

applicable
Adjusted Total Income under AMT, where applicable 3

Net tax payable 4

Taxabl
Interest and Fee Payable 1,000

Total tax, interest and Fee 6 1.000

payable
Taxes Paid 17,477

() Tax Payable /(-) Refundable (6-7) 8 (-) i6,480

[etail
lax
Accreted Income as per scction 115TD 9 0

Additional Tax payable w/s 1ISTD 10

Interest payable u/s 115TE 11

Accre
Additional Tax and interest payable 12

Tax and interest paid 13

(t)Tax Payable /(-) Refundable (12-13) 14 0

Income Tax Return submitted clectronically on 29-Dec-2022 12:58:|from IP address 1.23.249.133 and verified by SURESH
SAHADEV
ADHAV having PAN AFPPJI614M on 02-Jan-2023 using paper ITR-Verification Form /Electronic Verification Code
7F3EFF7ZTI
erated through Aadhaar OTP mode

System Generated

Bareode/QR Code
AFPPJI614M0487954573029 1222D99B80C3AS055AAS3352C445C81F8EDC3CA61B7A
ND THISACKNOWLEDGEMENT TO CPC. BENGALURU

. i nis verifiel after s0 das of transmission of returndata electronically, then date of

ods dite of iling the return (Notiication No.05 of 202? duted verification wil! be
29-07-2022 issued by the DGIT (Systs)

Certified True Copy

Or Kurmar Mhatro &. Co.
(nariorod Aeouaiarnts

(Kumav.Mhatro)
Propriotor
Mernhership No. 1O0103