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To ensure that your payment is received by your institution without any delays, please follow the
instructions below:
Due to Indian regulations, in order to complete your payment you will need to present the attached Outward Remittance Request
Form along with proof of identity and address at a local ICICI Bank branch.
To find the nearest ICICI Bank branch, please use their branch locator by clicking Here.
1.Print the Outward Remittance Request and Payment Instructions forms
2.Fill out the Outward Remittance Request form. Note that much of the information has been pre-populated for your convenience.
Below are the items which are to be completed by the person making the INR payment (remitter). It is important that all items
below are completed in full to ensure efficient processing of your payment.
Section 1: The remitter fills in their Name, Address and Phone Number.
Section 2.b: Fill in the designated amount of INR shown on the attached instructions in words. Ensure that the amount populated
in numbers as well.
Section 3: ICICI ACCOUNT HOLDERS ONLY - The remitter provides the ICICI INR account number to be debited for the
payment. (Non-ICICI account holders see Item 4 below)
Section 5: Provide the Student Name, Student ID and Country of Study Abroad.
Section 6: Please ensure that the ICICI representative includes the displayed Reference Number with the wire payment.
Signature: The remitter signs and dates the Outward Remittance Request at the end of the Declaration on Page 3.
3.Take the printed/signed documents and present your proof of identify and address for verification by ICICI Bank*. The ICICI
representative will complete the KYC Certification with the remitter as applicable. Acceptable identification includes:
Proof Of Identity

Proof Of Address

Passport

Passport

PAN Card

Telephone bill

Voter ID Card

Electricity bill

Driving License

Bank Statment with cheque

Government ID Card

Certificate/ID Card/ Savings Pass Book issued by Post Office

Photo ration card

Latest premium receipt of any life insurance co

Senior citizen ID card

Consumer gas connection card/book/Pipe gas bill


Leave/Lease and License Agreement

4.Non-ICICI account holders will transfer funds locally from their respective bank accounts to ICICI Bank pool account through
NEFT/RTGS as per the details mentioned below:
Beneficiary Name: Outward Remittance Pool Account
Account Number: 0035SLORCBPC
IFSC Code: ICIC0000035
5.ICICI Bank will process your request. Western Union Business Solutions (USA), LLC will then deliver the USD payment to
your school to complete the payment.

The following quote is valid until:

07 January 2016 15:25 GMT

You cannot use this sheet after this date. If the date above has passed, go online again and create a new quote. Note that there will be a small
processing fee charged by ICICI Bank.

A2 CUM RETAIL OUTWARD REMITTANCE APPLICATION


For Official Use only

Originating Br. ID

Track Number

Scan Br. ID

AD Code

(To be completed by the applicant in block letters using black ink pen)
Application for drawal of Foreign Exchange
I. Details of the Applicant (Remitter)
a. Name of the Applicant
b. Address (Not mandatory
for ICICI A/c holders)
Applicant Phone numbers
II. Details of Foreign Exchange required (Fill-up either II a or II b) (Ref Annex-II in page 6 for applicable
Currency Details)
II a. For remittance of fixed amount of Foreign Currency
Foreign Currency

FC
Amount In
Words

FC Amt in figures

(OR) II b. For remittance of equivalent of Foreign Currency of Fixed Rupee Amount


Foreign Currency

USD

INR Amt in figures

1191598.96

INR
Amount In
Words

II c. Purpose of Remittance with Purpose Code (For details refer Annexure - I in page 4)
Code

Description

Education

S1107

III. I / We authorize you to debit my / our below Account together with your charges
* Charges
borne by
beneficiary
(BEN)

* Charges
borne by
remitter
(REM)

* Charges will be to the Account of Beneficiary (BEN) if no option is selected


III a. Please issue
Telegraphic Transfer (TT)

(or) Demand Draft (DD)

Beneficiary Name
W

U
N

B
A

Beneficiary Address
1

W A S H

1
I

T H

S T R E E T

N G T O N

D C

IV a. Beneficiary A/c Number (Incase of TT)


1

N W
0

T H

L O O R

A2 CUM RETAIL OUTWARD REMITTANCE APPLICATION


IV b. Name of the Bank where the beneficiary A/c is maintained (In case of TT)
U S

B A N K

IV c. SWIFT & SORT Code details of beneficiary Bank (In case of TT)
IBAN for remittance made to
UK, Europe, Bahrain Saudi
Arabia & UAE
Sort Code for remittance to
UK (or) BSB Code for
remittance to Australia

SWIFT code (or) routing Number for


remittance to any other Country

USBKUS44IMT
104000029

A2 CUM RETAIL OUTWARD REMITTANCE APPLICATION


IV d. Beneficiary Bank address including Country at which the beneficiary maintains A/c ( mandatory in case of TT in
CAD Currency)

F A R N A M

O M A H A

S T

R E E T

N E B R A S K A

IV e. Furnish the following details of Correspondent Bank if the Foreign Currency is sent to a Country other than the
home Country of the Currency

SWIFT Code

Correspondent Bank Name

V. If the purpose selected is one of the below then it is mandatory to furnish the details sought for
Maintenance

The relationship of beneficiary with the remitter (for list of close relatives refer the table given
below)

Education

The Student Name and Student ID (if any). Country of study abroad

Purchase of
Property

The location of property being purchased (Country / State)

Investment abroad

Nature of instrument (Equity / MF / Debt Instrument) and country of incorporation of the


company in which the investment is made

Details

List of close relatives as per Sec VI of Companies Act


Brother (including step Brother)

Daughters Sons Wife

Mother (including Step Mother)

Sons Daughter

Brothers wife

Daughters Husband

Mothers Father

Sons Daughters Husband

Daughter (Including Step Daughter)

Father

Mothers Mother

Sons Son

Daughters Daughter

Fathers Father

Sister (Including Step Sister)

Sons Sons wife

Daughters Daughters Husband

Fathers Mother

Sisters Husband

Sons wife

Daughters Son

Member of HUF

Son (Including step Son)

Husband (or) Wife

VI. Furnish below if a message to be sent along with wire transfer on your behalf
US528557OU3636

INR
Declaration

I / We hereby declare that the total amount of foreign exchange purchased from or remitted through all sources in India during this Calendar /
Financial year including this application is within USD Limit as prescribed by RBI for the said purpose under FEMA 1999
(Tick the appropriate box).
<- - - - - - - - - - - - - - - - - - - - - - - - - - - -Limit Category- - - - - - - - - - - - - - - - - - - - - - - - - - - ->

Customer Category

USD
1 Lac

USD
2 Lacs

Resident Indian
NRI/PIO
a) NRE / FCNR A/c
b) NRO A/c of an NRI
c) NRO A/c of a PIO
Foreign National
a) Foreign Tourist
b) Employed in India
c) Employed In India ( not permanently
resident)
Trust / Association / Society /
Club
If Limit Category "Others" is chosen then enclose necessary support document.

USD
10 Lacs

Net
Salary

No Limit

Others (Mention the limit in USD)

A2 CUM RETAIL OUTWARD REMITTANCE APPLICATION


I/ We hereby declare that the transaction mentioned above doesnt involve, and is not designed for any purpose for which the drawing of
foreign exchange is prohibited under rule 3 of the FEMA Current A/c transactions Rules, 2000 read with schedule I therefore of Viz,
1.
2.
3.
4.
5.

Travel to Nepal & or Bhutan


Transaction with a person resident in Nepal or Bhutan
Remittance out of lottery winnings
Remittance of Income from Racing / riding etc. or any other hobby.
Remittance for purchases of Lottery tickets, banned or prescribed magazines, football pools, sweep stakes, schemes involving money
circulations, securing prize money awards etc.
6. Payment of commission on exports made towards equity investments in joint ventures / wholly owned subsidiaries abroad of Indian Companies
7. Remittance of dividend by any company to which the requirement of dividend balancing is applicable.
8. Payment of commission on export under rupee state credit route except commission up to 10% in invoice value of exports of Tea & Tobacco.

I / We, being a person(s) resident in India, hereby declare that for transactions done under the Liberalized Remittance Scheme (LRS) for resident
individuals, issued and amended by RBI from time to time, is not in the nature of remittance for margin calls to overseas exchanges/ overseas
counter parties under this scheme.
I / We, being a person(s) resident outside India, here by declare that under Sec 4(b) of FEMA Permissible Capital A/c Transaction regulation, 2000,
the transaction mentioned above doesnt involve and is not designed for any repatriation outside India out of the proceeds of any investment in India,
in any form, in any Company, Partnership firm (or) Proprietary concern or any entity, whether incorporated or not, which is engaged or proposes to
engage
a. In the business of chit funds or
b. As Nidhi company or
c. In agricultural or plantation activity, or
d. In real estate business, or construction of farm houses (real estate business shall not include development of townships construction of
residential / commercial premises roads or bridges), or

I / We being a person(s) resident outside India, here by declare that no portion / part of outward remittance represents interest on refunds of funds
received from outside India for purchase of shares in India. Updated list of prohibited transactions under FEMA can be accessed on
ICICI Bank website www.icicibank.com

Other relevant declarations:


I/we hereby declare that the purpose and transaction details as mentioned above are true to the best of my knowledge does not involve, and is not
designed for the purpose of any contravention or evasion of the provisions of the FEMA, 1999 or any rule, regulation, notification, direction or order
made there under. I/We agree that I/We shall be responsible and liable for any incorrect detail provided by me/us.
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 agree that in the event of transaction could not be executed/debited to my/ our account after submitting the request for processing to the bank
on account of insufficient/ unclear balance at the same time of execution of the transaction in my/ our account any exchange
losses incurred in this connection due to reversal of the Forex deal can be charged to my/our ICICI account.
I/we agree that in the event the transaction is cancelled or revoked by me/us after submitting the request for processing to the bank any exchange
losses incurred in this connection can be charged to my/our ICICI account. I/we further agree that once the funds remitted by me/us have been
transmitted by ICICI bank to the correspondent and/or beneficiary banks, ICICI bank shall not be responsible for any delays I the disbursement of
such funds including the withholding of such funds by the correspondent and/or beneficiary banks. I/We further agree that once the funds remitted by
me / us have been transmitted by ICICI Bank, intermediary Bank charges may be levied by Correspondent and / or Beneficiary Banks, which may
vary from bank to bank.
I/we agree that in the event the transaction being rejected by the beneficiary bank because of incorrect information submitted by me, any
charges levied by the beneficiary bank or exchange losses incurred in this connection can be charged to my ICICI bank account.
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 in contemplated by me/us, report that
matter to the RBI.
I/we also agree that the exchange rate will be applicable at the time of deal booking and may vary from the rate prevailing when the request is
submitted . I/we also understand that the rate communicated to us (if any) is an indicative rate and the actual rate may be different from the same.
I / We authorize you to remit outwardly as per details provided in the application.
...............................................

Signature of Remitter / Mandate


Date............................

Holder
(The signature by mandate holder will be accepted only for Non resident A/c holders where mandate is duly registered with the Bank )

I certify that I have verified the Customers signature as per Bank records and retained the originals of all the scanned documents and
forms submitted by the remitter for the above transaction.

Name & employee ID

Bank Stamp & Employee Signature

A2 CUM RETAIL OUTWARD REMITTANCE APPLICATION


(For Official Use only)
Annexure-III

KYC Certification
(To be filled and scanned only in case of remittance by non ICICI Customer)
I met Mr./Ms./Mrs. _______________________________ at his / her residence / office / other location (specify)
________________________________ and hereby confirm the identity and address given below
1. Remitter Name

2. Remitter Address

I confirm having verified the copies of documents (as applicable) with the originals produced by the applicant.
Also I confirm that the applicant has signed the documents in my presence. List of KYC documents provided.

ID Proof
Address Proof

Name of the Bank official ___________________________ Employee No. ____________ Designation__________

Date : _______________

Signature of the Branch Official and Branch stamp

Name of BM / BOM authorizing KYC certification above ______________________ Employee No.__________

Date : _______________

Signature of the Branch Official and Branch stamp

Details of INR amount credited to the pool a/c (Incl. of Charges + Service Tax) _______________________
Finacle Tran ID. _________________ IBR No. _____________________ Date of credit ______________________
into Pool A/c No.0035SLORCBPC (incase of any other a/c specify) ___________________________

(If the remittance is by way of accepting cash deposit then the amount should not exceed INR 50,000/-)