Page 1 of 6

MHW1/181D/1-1/WBF-M/03-12

MR.BARATHKUMAR S
021201594150??SIVA0807 636804
NO 7/110, AMMAPALAYAM,THOTTAM,THOPPAMPALAYAM Your Base Branch: ICICI BANK LTD., DOOR
MR.SIVAMANI K
THAPALLI, BAGUTHAMPALAYAM IKKARAITHA ERODE NO.1414A,,AMBAL NAGAR, SATHY MAIN ROAD,,641006
NO 3/416, BOODHANALLI KOTTAI
BOODHANALLI, DHARMAPURI
SALEM Visit www.icicibank.com
TAMIL NADU - INDIA - 636804 Dial your Bank B479

Did you know? It's mandatory to be KYC compliant as per RBI guidelines. If you have not submitted your KYC documents, please visit the nearest
branch or contact your Relationship Manager to complete KYC details for your Account.

Summary of Accounts held under Cust ID: 536433172 as on May 18, 2021
ACCOUNT DETAILS - INR
ACCOUNT TYPE A/c BALANCE(I) FIXED DEPOSITS (LINKED) BAL.(II) TOTAL BALANCE(I+II) NOMINATION
Savings A/c 021201594150 723.45 0.00 723.45 Not Registered
TOTAL 723.45 0.00 723.45

Statement of Transactions in Savings Account Number: 615201539091

021201594150 in INR for the period February 01, 2021 - May 18, 2021
DATE MODE** PARTICULARS DEPOSITS WITHDRAWALS BALANCE
01-02-2021 B/F 22,983.29
01-02-2021 OTHER ATMS NFS/MC002103/CASH WDL/31-01-21 1,000.00 21,983.29
MMT/IMPS/103117566386/Family/SARADHA/IDIB0
01-02-2021 MOBILE BANKING 00N035 13,000.00 8,983.29
BIL/000032810706/ICICI BANK CREDIT
01-02-2021 NET BANKING CA/474846805165 1,899.00 7,084.29
BIL/ONL/000032813266/Citibank
01-02-2021 N/CITICARD_VICI97/City credit car 2,677.69 4,406.60
MMT/IMPS/103118590343/Family/Kanakaraj/IDIB00
01-02-2021 MOBILE BANKING 0P154 2,000.00 2,406.60
01-02-2021 BIL/RCHG/000032904104/Vi-Tamil N/9047809475 50.00 2,356.60
01-02-2021 UPI/103217261067/UPI/barathseelan97@/ICICI Bank 1,000.00 3,356.60
MMT/IMPS/103220963099/hi/SARADHA KA/Indian
01-02-2021 MOBILE BANKING Bank 10,000.00 13,356.60
UPI/103220290896/Hi/jerinmech18-1@o/Karur
01-02-2021 Vysya Ban/ 8,000.00 5,356.60
MMT/IMPS/103220746548/Family/SARADHA/IDIB0
01-02-2021 MOBILE BANKING 00N035 5,000.00 356.60
MMT/IMPS/103221968590/hi/SARADHA KA/Indian
01-02-2021 MOBILE BANKING Bank 3,000.00 3,356.60
02-02-2021 BIL/RCHG/000035288235/Vi-Tamil N/9047809475 49.00 3,307.60
04-02-2021 ICICI ATM ATM/SACWN676/CASH WDL/04-02-21 1,000.00 2,307.60
UPI/103617475738/Family/kanagarajmariap/Indian
05-02-2021 Bank 4,200.00 6,507.60
MMT/IMPS/103708822407/Family/Kanakaraj/IDIB00
06-02-2021 MOBILE BANKING 0P154 4,200.00 2,307.60
06-02-2021 ACH/HDFC BANK LIMITED/0000061706040 1,744.00 563.60
08-02-2021 UPI/103810255510/NA/viprevf@hsbc/ 149.00 414.60
08-02-2021 UPI/RVSL103810255510/NA/viprevf@hsbc/ 149.00 563.60
08-02-2021 BIL/RCHG/000039279091/Vi - Tamil/9655697604 149.00 414.60
UPI/103820271171/Sivamani/jerinmech18@oki/Karu
08-02-2021 r Vysya Ban 8,002.00 8,416.60
MMT/IMPS/103822678260/Family/SARADHA/IDIB0
08-02-2021 MOBILE BANKING 00N035 8,000.00 416.60
MMT/IMPS/103822678260/Family/SARADHA/IDIB0
08-02-2021 MOBILE BANKING 00N035 8,000.00 8,416.60
MMT/IMPS/103822679352/Family/SARADHA/IDIB0
08-02-2021 MOBILE BANKING 00N035 8,000.00 416.60
 Page 2 of 6

MR.BARATHKUMAR S
MR.BARATHKUMAR S
MR.SIVAMANI K

DATE MODE** PARTICULARS DEPOSITS WITHDRAWALS BALANCE

MMT/IMPS/103822679352/Family/SARADHA/IDIB0
08-02-2021 MOBILE BANKING 00N035 8,000.00 8,416.60
MMT/IMPS/103917566752/Family/SARADHA/IDIB0
08-02-2021 MOBILE BANKING 00N035 8,000.00 416.60
15-02-2021 BIL/RCHG/000044609831/Airtel - T/7373124322 48.00 368.60
15-02-2021 BIL/RCHG/000044744728/Airtel - T/7373124322 249.00 119.60
UPI/104618439597/Hi/gpay-1116642523/Axis Bank
15-02-2021 Ltd. 110.00 9.60
UPI/104622300390/Tsfr/vinoth.eee98@ok/State
15-02-2021 Bank Of I 500.00 509.60
18-02-2021 OTHER ATMS NFS/48102119/CASH WDL/18-02-21 200.00 309.60
20-02-2021 BIL/RCHG/000049127966/Airtel - T/8012453263 48.00 261.60
UPI/105119849142/UPI/mm408390@oksbi/State
20-02-2021 Bank OfI 1.00 262.60
UPI/105119835352/UPI/mm408390@oksbi/State
20-02-2021 Bank OfI 1,000.00 1,262.60
22-02-2021 OTHER ATMS NFS/MW002104/CASH WDL/21-02-21 1,000.00 262.60
UPI/105711308471/Jerin/jerinmech18@oki/Karur
26-02-2021 Vysya Ban 4,003.00 4,265.60
NEFT-CITIN21131964579-LAKSHMI MACHINE
26-02-2021 WORKS LIMITED-SALARY-0070004003- 22,859.00 27,124.60
CITI0000011
UPI/105719383649/Feb 2021/S K LAKSHMI
26-02-2021 GOL/Canara Bank/ 1,000.00 26,124.60
26-02-2021 BIL/INFT/000053951115/Friends/ SANTHOSH A 4,000.00 22,124.60
MMT/IMPS/105813681472/Friends/Kanakaraj/IDIB00
01-03-2021 MOBILE BANKING 0P154 3,500.00 18,624.60
UPI/105818147408/Family/mrkkanagu@okaxi/Indian
01-03-2021 Bank 1,000.00 19,624.60
01-03-2021 ICICI ATM ATM/SACWN676/CASH WDL/28-02-21 1,000.00 18,624.60
UPI/106021199091/Hi/jerinmech18@okh/Karur
01-03-2021 Vysya Ban/ 8,000.00 10,624.60
03-03-2021 BIL/RCHG/000058671673/Vi-Tamil N/9047809475 49.00 10,575.60
UPI/106415127611/Family/mrkkanagu@okaxi/Indian
05-03-2021 Bank 4,200.00 14,775.60
05-03-2021 ICICI ATM ATM/SACWJ021/CASH WDL/05-03-21 5,500.00 9,275.60
UPI/106421425174/UPI/sivamukesh333@o/ICICI
05-03-2021 Bank 10,000.00 19,275.60
VPS/CKM FUELS
08-03-2021 DEBIT CARD S/202103071604/106610611348/DHARMAPUR 500.00 18,775.60
08-03-2021 OTHER ATMS NFS/S1DN0351/CASH WDL/07-03-21 8,000.00 10,775.60
UPI/106614418242/Hi/sb.mano51@oksbi/State Bank
08-03-2021 OfI/ 1.00 10,774.60
UPI/106614432949/Pump/sb.mano51@oksbi/State
08-03-2021 Bank Of I/ 9,000.00 1,774.60
08-03-2021 BIL/RCHG/000062240540/BSNL-Tamil/9489721729 50.00 1,724.60
UPI/106719402099/UPI/arunkumar20196v/Canara
08-03-2021 Bank 1.00 1,725.60
UPI/106757661997/NA/9655130004@payt/Karur
08-03-2021 Vysya Ban 4,004.00 5,729.60
08-03-2021 UPI/106722448519/Hi/sivamukesh333@o/ICICI Bank 5,000.00 729.60
UPI/106820715177/Payment from
09-03-2021 Ph/9790362731@ybl/State Bank Of I 1,000.00 1,729.60
NEFT-CITIN21138348008-LAKSHMI MACHINE
09-03-2021 WORKS LIMITED-KAIZEN-0070004003-CITI0000011 50.00 1,779.60
UPI/106818104998/Hi/santhoshkumar28/Indian
09-03-2021 Bank 1.00 1,778.60
UPI/106818110740/Hi/santhoshkumar28/Indian
09-03-2021 Bank 1,000.00 778.60
09-03-2021 OTHER ATMS NFS/BPCN2325/CASH WDL/09-03-21 500.00 278.60
UPI/106820341549/UPI/smartsanjay.god/Indian
09-03-2021 Bank 9,300.00 9,578.60
09-03-2021 UPI/106820019904/Hi/sivamukesh333@o/ICICI Bank 5,000.00 4,578.60
 Page 3 of 6

MR.BARATHKUMAR
MR.SIVAMANI K S

DATE MODE** PARTICULARS DEPOSITS WITHDRAWALS BALANCE

UPI/106820043840/Mar 2021/S K LAKSHMI
09-03-2021 GOL/Canara Bank/ 1,000.00 3,578.60
UPI/106820053330/Tq/vinoth.eee98@ok/State Bank
09-03-2021 OfI/ 500.00 3,078.60
UPI/106820062100/Hi/mm408390@oksbi/State
09-03-2021 Bank Of I 1,000.00 2,078.60
UPI/107006004224/UPI/vthangavelu81@o/Andhra
11-03-2021 Bank 1,300.00 778.60
UPI/107018438428/Hi/gpay-1116642523/Axis Bank
11-03-2021 Ltd. 88.00 690.60
12-03-2021 VISA REF CKM FUELS STATION 3.75 694.35
15-03-2021 OTHER ATMS NFS/IOBD7650/CASH WDL/14-03-21 500.00 194.35
UPI/107405194032/urgent/santhoshkumar28/Indian
15-03-2021 Bank 1,000.00 1,194.35
18-03-2021 BIL/INFT/000070400130/Friends/ SANTHOSH A 2,000.00 3,194.35
BIL/ONL/000072448571/Citibank
20-03-2021 N/CITICARD_VICI98 2,837.51 356.84
UPI/108318316524/Hi/q12168937@ybl/HDFC BANK
24-03-2021 LTD 145.00 211.84
UPI/108620304148/UPI/kanakarajt1992@/Lakshmi
29-03-2021 Vilas B/ 55.00 156.84
UPI/108817804088/Family/kanagarajmariap/Indian
29-03-2021 Bank 1.00 157.84
UPI/108817812727/Family/kanagarajmariap/Indian
29-03-2021 Bank 200.00 357.84
29-03-2021 BIL/INFT/000078512421/Friends/ SANTHOSH A 200.00 157.84
29-03-2021 BIL/INFT/000078516812/Friends/ SANTHOSH A 200.00 357.84
UPI/108817221872/UPI/paytmqr28100505/Paytm
29-03-2021 Payments/ 100.00 257.84
30-03-2021 021201594150:Int.Pd:30-12-2020 to 29-03-2021 36.00 293.84
30-03-2021 BIL/INFT/000079270606/Family/ SANTHOSH A 360.00 653.84
UPI/108917084326/Santhosh/q44529834@ybl/Yes
30-03-2021 Bank Ltd/ 355.00 298.84
NEFT-CITIN21149883307-LAKSHMI MACHINE
31-03-2021 WORKS LIMITED-SALARY-0070004003- 23,649.00 23,947.84
CITI0000011
NEFT-CITIN21149893162-LAKSHMI MACHINE
31-03-2021 WORKS LIMITED-MEDICAL-0070004003- 2,799.00 26,746.84
CITI0000011
31-03-2021 OTHER ATMS NFS/BPCN2325/CASH WDL/31-03-21 1,000.00 25,746.84
31-03-2021 OTHER ATMS NFS/IOBD7650/CASH WDL/31-03-21 1,000.00 24,746.84
UPI/109220138393/Hi/arunkumar20196v/State Bank
02-04-2021 OfI/ 1.00 24,745.84
UPI/109220155057/Ho/arunkumar20196v/State
02-04-2021 Bank OfI/ 3,000.00 21,745.84
UPI/109320055244/Hi/nrameshraja592@/State Bank
03-04-2021 OfI/ 300.00 21,445.84
05-04-2021 OTHER ATMS NFS/TMB13802/CASH WDL/04-04-21 1,500.00 19,945.84
05-04-2021 OTHER ATMS NFS/TMB13802/CASH WDL RVSL/04-04-21 1,500.00 21,445.84
05-04-2021 OTHER ATMS NFS/TMB13802/CASH WDL/04-04-21 2,000.00 19,445.84
UPI/109407273775/UPI/nrameshraja592@/State
05-04-2021 Bank Of I/ 500.00 18,945.84
UPI/109407209835/Rewarded for pa/goog-
05-04-2021 payment@ok/Axis Bank Ltd. 5.00 18,950.84
05-04-2021 UPI/109416245802/UPI/viprevf@hsbc/HSBC 499.00 18,451.84
05-04-2021 BIL/RCHG/000084338952/Airtel - T/8012453263 48.00 18,403.84
05-04-2021 BIL/RCHG/000084898176/Vi-Tamil N/9047809475 49.00 18,354.84
UPI/109711456726/Family/kanagarajmariap/Indian
07-04-2021 Bank 1.00 18,355.84
UPI/109711463482/Family/kanagarajmariap/Indian
07-04-2021 Bank 2,000.00 20,355.84
UPI/109719313606/7 April 2021/S K LAKSHMI
07-04-2021 GOL/Canara Bank/ 1,000.00 19,355.84
08-04-2021 ICICI ATM ATM/SACWN676/CASH WDL/08-04-21 3,500.00 15,855.84
 Page 4 of 6

MR.SIVAMANI K
MR.BARATHKUMAR S

DATE MODE** PARTICULARS DEPOSITS WITHDRAWALS BALANCE

09-04-2021 UPI/109916459966/UPI/raja.ram.kumar1/ICICI Bank 100.00 15,755.84
MMT/IMPS/109922457755/Family/SARADHA/IDIB0
09-04-2021 MOBILE BANKING 00N035 15,000.00 755.84
MMT/IMPS/109922457755/Family/SARADHA/IDIB0
09-04-2021 MOBILE BANKING 00N035 15,000.00 15,755.84
MMT/IMPS/109922459011/Family/SARADHA/IDIB0
09-04-2021 MOBILE BANKING 00N035 15,000.00 755.84
MMT/IMPS/109922459011/Family/SARADHA/IDIB0
09-04-2021 MOBILE BANKING 00N035 15,000.00 15,755.84
BIL/NEFT/000089269191/Family/SARADHA
09-04-2021 /IDIB000N035 15,000.00 755.84
UPI/110007052883/UPI/pushpasri2004@o/State
12-04-2021 Bank Of I/ 48.00 707.84
NEFT-CITIN21156415578-LAKSHMI MACHINE
12-04-2021 WORKS LIMITED-TRAADV-0070004003- 2,000.00 2,707.84
CITI0000011
14-04-2021 UPI/110417240231/UPI/cokeram@okicici/ICICI Bank 1,580.00 4,287.84
MMT/IMPS/110521665163/NA/KANAKARAJ
15-04-2021 MOBILE BANKING /Allahabad Bank 10.00 4,297.84
MMT/IMPS/110522665230/NA/KANAKARAJ
15-04-2021 MOBILE BANKING /Allahabad Bank 600.00 4,897.84
BIL/ONL/000094892517/Citibank
17-04-2021 N/CITICARD_VICI99/Mar credit card 3,720.83 1,177.01
UPI/110819028388/Hi/paytmqr28100505/Paytm
19-04-2021 Payments 289.00 888.01
19-04-2021 BIL/INFT/000095994482/Family/ SANTHOSH A 2,166.00 3,054.01
19-04-2021 UPI/110918255011/UPI/kalimuthumuruga/ICICI Bank 5,000.00 8,054.01
19-04-2021 ICICI ATM ATM/SECPR398/CASH WDL/19-04-21 3,500.00 4,554.01
MMT/IMPS/110919785272/Family/SARADHA/IDIB0
19-04-2021 MOBILE BANKING 00N035 2,000.00 2,554.01
UPI/111113278526/UPI/paytmqr28100505/Paytm
21-04-2021 Payments/ 1,640.00 914.01
VPS/SHRI
26-04-2021 DEBIT CARD KANNAN/202104241830/111413775934/COIMBATO 206.20 707.81
R
UPI/111517396292/Hi/vinoth.eee98@ok/State Bank
26-04-2021 OfI/ 100.00 607.81
UPI/111517507798/UPI/goog-payment@ok/Axis
26-04-2021 Bank Ltd. 5.00 612.81
UPI/111517519639/Earned for usin/goog-
26-04-2021 payment@ok/Axis Bank Ltd. 5.00 617.81
MMT/IMPS/111818382013/NA/KANAKARAJ
28-04-2021 MOBILE BANKING /Allahabad Bank 1,000.00 1,617.81
28-04-2021 ICICI ATM ATM/SACWN676/CASH WDL/28-04-21 500.00 1,117.81
MMT/IMPS/111907843084/Friends/Kanakaraj/IDIB00
29-04-2021 MOBILE BANKING 0P154 1,100.00 17.81
NEFT-CITIN21166276640-LAKSHMI MACHINE
30-04-2021 WORKS LIMITED-SALARY-0070004003- 33,961.00 33,978.81
CITI0000011
IPS/IOCL
30-04-2021 DEBIT CARD FREEDO/202104301832/000000028483/COI-COIMB 500.00 33,478.81
01-05-2021 UPI/112107179076/Hi/kalimuthumuruga/ICICI Bank 5,000.00 28,478.81
MMT/IMPS/112114014575/Friends/SARADHA/IDIB0
01-05-2021 MOBILE BANKING 00N035 25,000.00 3,478.81
MMT/IMPS/112114014575/Friends/SARADHA/IDIB0
01-05-2021 MOBILE BANKING 00N035 25,000.00 28,478.81
MMT/IMPS/112114016037/Family/SARADHA/IDIB0
01-05-2021 MOBILE BANKING 00N035 10,000.00 18,478.81
MMT/IMPS/112114016037/Family/SARADHA/IDIB0
01-05-2021 MOBILE BANKING 00N035 10,000.00 28,478.81
BIL/NEFT/000104298255/Family/SARADHA
01-05-2021 /IDIB000N035 10,000.00 18,478.81
BIL/NEFT/000104298798/Family/SARADHA
01-05-2021 /IDIB000N035 15,000.00 3,478.81
IPS/Shree
01-05-2021 DEBIT CARD annaa/202105011934/000000007987/COIMBATOR 159.00 3,319.81
 Page 5 of 6

MR.SIVAMANI K
MR.BARATHKUMAR S
DATE MODE** PARTICULARS DEPOSITS WITHDRAWALS BALANCE
UPI/112317493878/UPI/gpay-1117314171/Axis Bank
03-05-2021 Ltd./ 325.00 2,994.81
UPI/112317175551/UPI/gpay-1116642523/Axis Bank
03-05-2021 Ltd./ 208.00 2,786.81
03-05-2021 OTHER ATMS NFS/12487929/CASH WDL/03-05-21 1,000.00 1,786.81
03-05-2021 BIL/RCHG/000106380455/Vi-Tamil N/9047809475 49.00 1,737.81
03-05-2021 Surcharge Dt:30/04/21 MCC 5541 2.36 1,735.45
04-05-2021 BIL/INFT/000106647359/Family/ SANTHOSH A 2,300.00 4,035.45
VPS/T PERUMAL
05-05-2021 DEBIT CARD N/202105050852/112503505781/COIMBATOR 682.00 3,353.45
05-05-2021 ICICI ATM ATM/SPCNF238/CASH WDL/05-05-21 1,000.00 2,353.45
UPI/112608244066/UPI/q74225710@ybl/Punjab
06-05-2021 National 90.00 2,263.45
UPI/112608253596/UPI/lakshmananfish@/Karur
06-05-2021 Vysya Ban/ 300.00 1,963.45
MMT/IMPS/112814985556/NA/KANAKARAJ
10-05-2021 MOBILE BANKING /Allahabad Bank 2,000.00 3,963.45
10-05-2021 BIL/INFT/000110799878/Family/ SANTHOSH A 3,900.00 63.45
UPI/112820141953/UPI/paytm-58526127@/Paytm
10-05-2021 Payments/ 30.00 33.45
MMT/IMPS/113122215271/NA/KANAKARAJ
11-05-2021 MOBILE BANKING /Allahabad Bank 1,200.00 1,233.45
12-05-2021 BIL/INFT/000113676723/Family/ SANTHOSH A 1,200.00 33.45
13-05-2021 BIL/INFT/000113956475/Family/ SANTHOSH A 1,000.00 1,033.45
UPI/113312149686/Hi/vinoth.eee98@ok/State Bank
13-05-2021 OfI/ 700.00 333.45
UPI/113407442543/UPI/gpay-1116642523/Axis Bank
14-05-2021 Ltd./ 65.00 268.45
UPI/113513208919/UPI/vinothmmavv@oki/ICICI
15-05-2021 Bank 500.00 768.45
15-05-2021 ICICI ATM ATM/SACWN676/CASH WDL/15-05-21 500.00 268.45
UPI/113513319858/UPI/paytm-58526127@/Paytm
15-05-2021 Payments/ 45.00 223.45
UPI/113518266941/trsfr/vinoth.eee98@ok/State
15-05-2021 BankOf I 700.00 923.45
UPI/113616077508/UPI/arunkumar20196v/Bank of
17-05-2021 India 200.00 723.45
TOTAL 2,53,050.75 2,75,310.59 723.45

Account Related Other Information

ACCOUNT TYPE ACCOUNT NUMBER MICR CODE IFSC CODE NAME OF NOMINEE
Savings 615201539091
021201594150 641229005
641229026 ICIC0006152
ICIC0004179 -

Nominee name is displayed only on specific consent of customer.

 Page 6 of 6

MR.SIVAMANI K

For ICICI Bank Limited

Authorised Signatory

Legends for transactions in your account statement

VAT/MAT/NFS - Cash Withdrawal at other bank's ATM INF - Internet funds transfer in Linked accounts
EBA - Transaction at ICICIDirect BIL - Internet bill payment or Funds transfer to third party
VPS/IPS - Debit card transaction TOP - Mobile Recharge
RTGS - Real Time Gross Settlement (Instant Transfer of Rs 2 Lakh and up to Rs 10 Lakh) NEFT - National Electronic Fund Transfer (Up to Rs 10 Lakh)
• **Mode is available only for transaction done after August 6, 2013.

• As per prevailing guidelines of the Income tax Act, 1961 if a valid PAN is not provided by the •In absence of valid PAN, Form 15G / 15H shall not be treated as valid and tax will be deducted.
Customer then tax shall be deducted at the prevailing rate or 20%, whichever is higher. •In case your PAN is not updated in our record, please visit the nearest branch and provide a copy
•As per guidelines issued by CBDT on May 13, 2011, Form 16A (TDS Certificates) will be generated of the PAN card along with the original PAN card for verification.
through the Income tax website for which the PAN of the customer needs to be necessarily updated •The address of the customer in Form 16A will be the last updated address in the data base of the
in Bank's record. Income tax department.

REGD ADDRESS: LANDMARK, RACE COURSE CIRCLE, VADODARA - 390 007, INDIA www.icicibank.com
This is an authenticated intimation/statement. Category of service: Banking & Financial Services.
Customers are requested to immediately notify the Bank of any discrepancy in the statement Registration No. MIV/ST/Bank & Finc/4.
MHW1-WBG-M-05-Mar-12/148405000053 - 525322040/207/207 - Utility - 1 of 1 PAN Based STC No. AAACI1195HSST001.