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DISBURSEMENT REQUEST FORM

To, Piramal Capital & Housing Finance Limited
Name of the Applicant(s) : RANJEET KAPIL SHARMA & SHEETALRANJEET
SHARMA

Loan Account Number: 0123456123111 (State the account number as
per the sanction letter)

Intended Date for Disbursement (DD/MM/YYY): 20/12/2017
Total Amount to be disbursed (in figures) : Rs. 15,27,000

Amount to be disbursed (in words) : Rs. FIFTEEN LACS TWENTY SEVEN
THOUSAND ONLY

Details of Disbursement Mode
Cheque
Sr. /DD/PO In favor of Payable Bank Bank Amt.
No. /RTGS at A/C No (Rs.)
/NEFT
1 006244 Aditya Devel- Mum HDFC 00001236412345 15,00,000
opers (Name of
the developer
should come)
2 06245 HDFC Standard Mum HDFC 00001236412345 25,000
Life
3 06246 HDFC Ergo Mum HDFC 00001236412345 2,000
Total 15,27,000
We authorize Piramal Capital & Housing Finance Ltd. to deduct/ adjust pend-
ing processing fee, pending charges/ fees, Broken Period Interest, Pre EMI In-
terest from above requested disbursement, as the case may be.

Declaration: The Applicant and the Co-applicants declare that the aforesaid
disbursement is being made strictly on their instruction and at their instance
in favor of the payee. We have exercised due care and caution,and conducted
the requisite due diligence in relation to the title of the property selected/
purchased and/ or mortgaged. We represent that all the requisite complianc-
es and approvals have been obtained.

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