Collecting Branch : EPS1 Servicing Branch : LIC of India, Br Office, P B No

P B No. 14 Kota Vari Street

Transaction No : 20235598
Railpet.,Repalle (Ap)
Date ( Time ): 19/02/2018 ( 16:42:17 ) Repalle,522265
bo_eps1@licindia.com
Receipt No : PR2023559800011718
HelpDesk: +91-022-1251

RENEWAL PREMIUM RECEIPT

Received with thanks ` 1,015.00 through Payment Gateway over the Internet from:

Smt./Ms./Shri : Ibrahim Khan

towards the following :

Policy No Plan Inst. Premium No Of Inst Total Premium CGST Branch

Name Term Mode Due From Late Fee SGST/UTGST Next Due
Agency Code D.O.C. Sum Assured Due To CD Charges Total Amt Reg. No.
(`) (`) (`)
676377070 91 1,015.00 1 1,015.00 0.00 67C
Ibrahim Khan 18 HLY 02/18 0.00 0.00 08/18
0063467C 19/08/2009 35,000.00 02/18 0.00 1,015.00

Page Total (`) 1,015.00 1,015.00 0.00

0.00 0.00
0.00 1,015.00
Grand Total (`) 1,015.00 1,015.00 0.00
0.00 0.00
0.00 1,015.00

GST borne by LIC of India ` 22.84

ONE THOUSAND FIFTEEN RUPEES AND ZERO PAISE ONLY

Ibrahim Khan
S/O Subhani Khan Late
5-9 --3,25th Ward,Near Nup School,
Repalle Po,Md Guntur Dt

522265 Payment Acknowledgement generated through

Online Portal on 24-Mar-19 Time : 10:06:58.
Mobile: 8374908485
Email: ibrahimsimplekhan@gmail.com

This receipt is electronically generated and no signature is required.

Har Pal Aapke Saath!