A2 CUM APPLICATION FORM FOR FOREIGN EXCHANGE PAYMENTS OVERSEAS UNDER LRS

To RBL Bank LTD, Branch : AD Code: 6160073-6000009

Applicant Name : PAN No:

Applicant Address CIF ID

Details of Foreign Exchange Required
A. Remittance Y/N Purpose Code
Currency Amount in
B.Forex Card Y/N Purpose Description
Type FCY
C. FCY Cash Y/N Travel Destination
Source of Fund Own Fund Family Fund Loan
Payment Details

Debit Authority: I/We authorize RBL Bank to debit my account:RBL Account No: ................................................................................................ to effect
the foreign exchange remittance / issue of Draft / FCY Notes / Forex Cards as detailed above (strike out which ever is not applicable) along with your
applicable charges (Commission, Foreign Conversion Tax, GST and Correspondent Bank Charges to my / our account No :
........................................................................................................................... (If other than the operative account).
Payment Details For Non-RBL Bank Account Holders
Type of Payment Instrument UTR No / Cheque No / Payment
(RTGS/NEFT/IMPS/Cheque/Cash) Reference No.
BENEFICIARY DETAILS
Residential Status of the
Beneficiary Name Beneficiary (Indian
Resident/NRI/OCI )

Beneficiary Address

Beneficiary Bank Name

Bank Address

Account Number Swift Code IBAN Number Routing No.

Student ID/REF. No
BSB / Sort Code/Transit No
(If required)
INTERMEDIARY BANK (IF ANY )
Bank Name Address Account No Swift Code

Bank Charges (Please tick whichever is applicable) BEN OUR SHA

Declaration (Under FEMA 1999)
□ I, ………….........................…….…………(Name), hereby declare that the total amount of foreign exchange purchased from or remitted through, all sources in India during the financial year
including this application is within the overall limit of the Liberalised Remittance scheme prescribed by the Reserve Bank of India and certify that the source of funds for making the said
remittance belongs to me and the foreign exchange will not be used for prohibited purposes.
□ The total amount of foreign exchange purchased from or remitted through all sources in India during the financial year as per LRS, is within the overall limit of USD 250,000/-(US Dollar Two
hundred and Fifty Thousand only), which is the limit prescribed by the Reserve Bank of India for the purpose
□Foreign exchange purchased from RBL Bank is for the purpose indicated above.
I hereby, □ Declare that the transaction details of which are specifically mentioned in the schedule hereunder 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
□ Agree and undertake to give such informa on / documents as will reasonably sa sfy you about this transac on in terms of the above declara on
□ Understand that if I/We refuse to comply with any such requirement or make any unsatisfactory compliance herewith, the Bank shall refuse in writing to undertake the transaction and shall
if it has reason to believe that my contravention / evasion is contemplated by me / us report the matter to Reserve Bank of India
Declaration for Relationship with the beneficiary for remittances under Family Maintenance
I………………...................……………...………, hereby declare that the beneficiary of this remittance is my….............…………………… (Relationship as per Sec VI of Companies Act.) The document
evidencing the relationship proof has been submitted correctly.

Date: Signature of the Applicant-------------------------------------------------------------------

Certificate by the Authorised 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
the Reserve Bank from time to time under the Scheme.
Currency Type Amount in FCY Amount in INR
Name and designation of the authorized official:
Branch Name & Code:
Date: Signature Stamp and Seal
□ Details of the remi ances made/transac ons effected under the Liberalised Remi ance Scheme in the current financial year is checked at the portal
provided by the RBI