Page No. 1 - ING Vysya Bank

AD Code No:
6310064-9200008
APPLICATION-CUM-DECLARATION FOR PURCHASE OF FOREIGN EXCHANGE UNDER THE LIBERALIZED
REMITTANCE SCHEME OF USD 125,000 FOR RESIDENT INDIVIDUALS
TO:
The MANAGER
ING VYSYA BANK LIMITED
_________________ Branch
Bill Ref No.
Transaction Ref No.
FDD No. ________________ ______issued (Branch to incorporate)
Dear Sir,
Sub: Request for Release of Foreign Exchange under LRS
I / We request you to release Forex as per the details given below:
I. PRODUCT REQUIRED: (Please tick the appropriate box)
Foreign Demand Draft
TT (Wire Transfer)
II. DETAILS OF REMITTER: (To be filled in Capital Letters)
A.
B.
NAME OF APPLICANT/REMITTER (As per CIF in
Profile)
DATE OF BIRTH OF APPLICANT/REMITTER
IN CASE OF MINOR - Application form to be signed
by minor and natural guardian along with Passport or
any other KYC document of both minor and natural
guardian (irrespective of whether they have an account
in the Bank or not). Both minor and natural guardian to
be screened mandatorily.
C.
ADDRESS OF REMITTER (As per Profile)
D
ACCOUNT NO. OF REMITTER
E
PAN No. (Mandatory)
F.
REMITTER CONTACT No.
G.
REMITTER Email ID
III. DETAILS OF FOREIGN EXCHANGE REQUIRED: (To be filled in Capital Letters)
A.
FCY AMOUNT (SPECIFY CURRENCY)
B.
FCY AMOUNT IN WORDS
C.
RATE
D.
SERVICE TAX
E.
CHARGES
F.
TOTAL INR (Figures & words)
IV. DETAILS OF PURPOSE: (Branch / Sales to assist Customer to fill appropriately)
A.
PURPOSE GROUP
B.
PURPOSE CODE
C.
PURPOSE DESCRIPTION
____________________________________________________
Signature of the Applicant / Remitter / Natural Guardian
Page No. 1
AD Code No:
6310064-9200008
APPLICATION-CUM-DECLARATION FOR PURCHASE OF FOREIGN EXCHANGE UNDER THE LIBERALIZED
REMITTANCE SCHEME OF USD 125,000 FOR RESIDENT INDIVIDUALS
V. DETAILS OF RELATIONSHIP WITH BENEFICIARY: (To be filled in Capital Letters)
A.
REMITTER RELATIONSHIP WITH BENEFICIARY
(Companies Act)
V. SOURCE OF FUNDS:
A.
SOURCE OF FUNDS
VI. DETAILS OF THE REMITTANCE MADE UNDER LRS SCHEME IN THE FINANCIAL YEAR (APR-MAR) 20______ 20_______ in sequential order:
A.
DATE OF REMITTANCE
B.
AMOUNT OF REMITTANCE
VII. BENEFICIARY DETAILS: (To be filled in Capital Letters)
A
BENEFICIARY NAME (In Capitals)
B
BENEFICIARY DATE OF BIRTH
C
BENEFICIARY COMPLETE ADDRESS (Mandatory)
D
BENEFICIARY A/C NO
(IBAN Mandatory for EUR / AED & SAR
Remittances)
E
INTERMEDIARY INSTITUTION SWIFT CODE
F
INTERMEDIAR INSTITUTION NAME & ADDRESS
G
BENEFICIARY BANK ACCOUNT NUMBER (To be
mentioned only if Beneficiary Bank Account held with
Intermediary Institution)
H
BENEFICIARY BANK SWIFT CODE
I
BENEFICIARY BANK NAME & ADDRESS
J
BENEFICIARY BANK SORT CODE/ ROUTING NO./
BSB NO. / TRANSIT NO. ETC.
K
SENDER TO RECEIVER INFORMATION (Additional
information to be provided in Field 70 of Swift – Eg.
Student Name / DOB/ PP No / Invoice No. Etc.
L
CHARGES OPTION FOR WIRE TRANSFER
OUR
SHA
BEN
(KINDLY TICK THE APPROPRIATE BOX FOR
CHARGES
Note: (For “OUR” option additional charges are
applicable to be collected upfront)
____________________________________________________
Signature of the Applicant / Remitter / Natural Guardian
Page No. 2
AD Code No:
6310064-9200008
APPLICATION-CUM-DECLARATION FOR PURCHASE OF FOREIGN EXCHANGE UNDER THE LIBERALIZED
REMITTANCE SCHEME OF USD 125,000 FOR RESIDENT INDIVIDUALS
VIII. DEBIT INSTRUCTION/AUTHORIZATION (Account Holder):
THIS IS TO AUTHORISE YOU TO DEBIT MY ACCOUNT No _______________________________ maintained at your
______________________ Branch together with your charges.
I / We hereby confirm that the funds being remitted is from my/our resident SB A/c No.__________________________, maintained with
_______________________ Bank; ____________ Branch; __________________ Place.
DECLARATION FOR JOINT ACCOUNT HOLDERS
Further, I declare that I ____________________________________________ am the joint holder of SB/FD/RD/Current Account bearing
No_____________________________ which stands in my name and in the name of Shri/Smt._________________________ who is my
_____________________(state relationship). I hereby undertake that I shall not use the proceeds lying in the above account for any transaction
in contravention of the provisions of the Foreign Exchange Management Act (FEMA) 1999, Rules/Regulations made there under and the
related circulars/instructions issued by the Reserve Bank from time to time. I further undertake that if any such transaction is put through the
said account in contravention of the FEMA, 1999 or Rules/Regulations made there under, I shall be held responsible for the same. I further
declare that the funds remitted through your Bank are from my / our Resident Account as mentioned above. I shall intimate my bank in the
event of any change in my Non-resident / Resident status.”
DECLARATION
I, ____________________________________ (Name), hereby declare that the total amount of foreign exchange purchased from or remitted
through, all sources in India during the financial year as per item No. V of the Application, including utilization of the said limit on account of loan
extended or gift made in rupees credited to NRO account of non-resident close relative(s), is within the limit of USD 125,000/- (US Dollar One
Lac Twenty Five thousand only), which is the limit prescribed by the Reverse Bank of India for the purpose and certify that the source of funds
for making the said remittance belongs to me and will not be used for prohibited purposes.
I/We, being a person resident in India, hereby declare that for transaction done under the Liberalized Remittance Scheme for resident
individual, issued and amended by Reserve Bank from time to time, is not in the nature of remittance for margins or margin calls to overseas
exchanges/ overseas counter party under the scheme.
I, hereby designate ING VYSYA Bank Ltd., _____________________ Branch for processing all remittances under Liberalized Scheme for the
financial year ___________.
I also hereby declare that I have not remitted under LRS from any other bank for the financial year ______________.
_________________________________________________
Signature of the Applicant / Remitter / Natural Guardian
Page No. 3
AD Code No:
6310064-9200008
APPLICATION-CUM-DECLARATION FOR PURCHASE OF FOREIGN EXCHANGE UNDER THE LIBERALIZED
REMITTANCE SCHEME OF USD 125,000 FOR RESIDENT INDIVIDUALS
DECLARATION (Under FEMA 1999)
I, ____________________________________ declare that –
1.
The total amount of foreign exchange purchased from or remitted through, all sources in India during this Calendar Year including this
application is within USD 125,000 (USD One Lac Twenty Five Thousand only), the annual limit prescribed by Reserve Bank of India
for the said purpose.
2.
Foreign Exchange purchased from you is for the purpose indicated above
DECLARATION – CUM – UNDERTAKING
(Under Section 10 (5), Chapter III of the Foreign Exchange Management Act, 1999)
I/We hereby declare that the purpose and transaction details as mentioned above are true to the best of my/our knowledge and does not
involve and is not designed for the purpose of any contravention or evasion of the provisions of the aforesaid Act or of any rule, regulation,
notification, direction or order made there under.
I/We declare that the subject transaction does not involve, and is not designed for any purpose for which the drawal of foreign exchange is
prohibited under Rule-3 of FEMA (Current Account Transactions) Rules, 2000; read with Schedule-I thereof.
I/We also hereby agree and undertake to give such information/documents as will reasonably satisfy you about this transaction in terms of the
above declaration.
I/ We also understand that if I/We refuse to comply with any such requirement or make only unsatisfactory compliance therewith, the Bank shall
refuse in writing to undertake the transaction and shall if it has reason to believe that any contravention/evasion is contemplated by me/us
report the matter to Reserve Bank of India.
*I/We further declare that the undersigned has/have the authority to give this declaration and undertaking on behalf of the firm/company
_________________________________________________
Signature of the Applicant / Remitter / Natural Guardian
Place
Date
:
:
DECLARATION FOR MINOR
I hereby declare that the Mr/Ms. ____________________ who is my ____________________________ is a minor and I am his/her
natural/lawful guardian appointed by the Court Order dated __ __ __.
_____________________________________________
Signature of Natural / Legal Guardian
Place
Date
:
:
(For Branch Use) Certificate
by the Authorized Dealer
This is to certify that the remittance is not being made by / to ineligible entities and that the remittance is in conformity with the
instructions issued by Reserve Bank from time to time under the scheme.
Name, Employee Number and Designation of the
Authorized Official Verified:
Signature of Authorized Official & Seal
Place:
Date:
Page No. 4

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