Declaration Cum Undertaking

To,
ICICI Bank Ltd
Bandra Kurla Complex
Mumbai-400051

Dear Sir / Madam,

I/We hereby declare and confirm that, all information and particulars given hereunder are
true correct, complete and up to date in all respects and that no information have been with
held by me/us for any reason whatsoever.

1 Following services are being provided by me/us to ICICI Bank Ltd

Sr. No Location Services provided

2. Following services are being provided by me/us to Banks other than ICICI Bank Ltd
Sr.No Banks Location Services provided

3.Following services are being provided by me/us to non-bank entities

Sl . No Other Non –Bank Entities Location Services Provided
4.-------------------------------------------------- is not a subsidiary of ICICI Bank and is not
owned or controlled by any director or officer/employee of ICICI Bank or their relatives
having the same meaning as assigned under section 6 of the companies Act 1956.

5. I/ we confirm that I/we follow the various regulatory norms/laws applicable to the
activities I/we are performing. I/we also confirm that I/we have duly executed and provided
all such documents/agreements that are required for the provision of the services I/we are
performing to ICICI Bank.

6.I/we confirm that I/we have conducted a comprehensive Pre-employment background

screening of each of the employee and maintain a complete record of each of the employee
including name, address, contact details and educational background etc.

7.There is no outstanding/potential litigation pending against me/us in any court of law.

Signed on this--------------day of------------------20----.

Name & Address Of Agency:--------------------------------------

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Name Of the Authorized Signatory:-----------------------------------

Signature of Authorized Signatory:--------------------------------------

Place:----------------------------