SERVICE REQUEST FORM

CRF No :____________________________ TI.No Dear Customer, We value your relationship with Axis Bank. Kindly fill this form in order to assist you at the earliest. Customer Name: DOB: Flat No. & Bldg. Name Road No./Name Landmark City State Tel (O) Mobile No. Existing Loan Details with Axis Bank Ltd Product: HL PL AL LAP Others Ext. Email ID STD Code Country Tel (R) Pin code D D M M Y Y Y Y Date: D D M M Y Y Y Y :____________________________

Communication Address:

Loan Account Number: Request pertains to : ( Tick which is applicable) DELIVERABLES RELATED: 1. Statement of Account 5. Original Documents 10.Foreclosure Statement 12. Rate Change Letter 2. IT Certificate Provisional 6. Welcome Kit 13. PDC Exhaust or Final 3. Repayment Schedule 8. Net Banking Related b) CNG Kit NOC 4. List / Copy of Documents 9. Insurance Policy Related d) Insurance NOC 7. Loan Agreement Copy

11. NOC Related : a) Closure NOC

c) Transfer NOC

PAYMENTS / REFUNDS RELATED: 1. Part Payment with effect on Tenure 4. EMI Related a) Payment 5. Charges Related CONTACT DETAILS: 1. Change in Contact Details: a) Name Change f) DOB correction Please Provide Details: b) Address Change g) Change in Co-Applicant c) Mobile No: Change d) Email ID or EMI 2. Swap Repayment mode to ECS c) EMI Amount Change 7. PF Refund SI PDC 3. Foreclosure Payment e) EMI Not Deducted 9. Other Refunds

b) Date Change

d) EMI Start Date

6. LNPPD Refund

8. Refund Excess EMI Collected

OTHER REQUESTS: Please provide Details:

Customer Signature: ________________________________________________________________

We have noted your request vide CRF No:__________________________ Details of instruments collected if any______________________________________________________ Thank You for banking with Axis Bank Ltd. Customer Care officer Name:_______________________________________________ Employee ID:____________________________ Sign & Seal of Bank Officer

CRITICAL INPUT FORM

(To be filled by Bank Official)
CRF No :____________________________ TI.No :____________________________ D D M M Y Y Y Y

Date: Request Complaint :

: 2. Foreclosure

Customer Name
Loan Account Number

1.Part payment with Tenure reduction or EMI Reduction By Cheque / DD

3. EMI Payment 4. Charges By Cash

1. Amount Rs 2. Cheque No 3. Cheque Dated 4. Bank Name 5. Deposited into A/c No 6. Tran ID 7. Amount Break Up
5.Repayment mode SWAP to ECS For PDC cases SI PDC

1. Amount Rs 2. Date of deposit 3. Deposited into A/c No. 4. Tran ID 5. Amount Break Up

1 Cheque No: 2 Cheque Date 3.Bank A/c no: 4.Bank Name:

submitted from ________________________________To________________________________ from ________________________________To________________________________ __________________________________ __________________________________ Old EMI ____________________________ New EMI ____________________________
D M M Y Y Y Y

6. EMI Related Date Change or Amount Change:

Old Date New Date

D D

D D

M M

M M

Y Y

Y Y

Y Y

Y Y

Broken Period Interest paid Rs____________________ vide chequeNo:______________ dated D Tran ID if paid by cash_______________________
7. Despatch of Original Documents at preferred location provide details:

RAC Name ________________________________________________________________________________________________

8. Waiver Approvals if any Attached Provide Details

Mail Dated D

Y , Approved By ____________________________________

9. Others (Specify)

Customer Care Officer Name : ______________________________________ Employee ID: ___________________

Sign & Seal of Bank Officer