A 4 - For Debits and Credits to Non-Resident Accounts of All types other than the Accounts of
Non-Resident Banks, Requiring Approval of Reserve Bank or for Report to Reserve Bank
(To be completed for debits and credits to non-resident accounts of all types other than the accounts of
non-resident banks, requiring approval of Reserve Bank or for report to Reserve Bank)
(To be printed on White paper)
For debit* from the account of __________ ___________ ___________ ___________ ___________
____________ ______________ ____________________ _______________ _____________________
(Name and address of non-resident account holder stating country of residence and type of account)
At ________ _________ ____________ ________ ______________ _____________ __________
_____
(Name of authorised dealer or authorised co-operative/ commercial bank with whom account is kept)
For payment to__________ ___________ __________ __________ ______
(Name and address of the resident beneficiary)
Amount Rs.________________ _______________ ___________________
(in figures) (in words)
The purpose of payment is ____________ _____________ _____________ ______________ ________
For credit* From ___________ __________ ____________ ____________
(Name and address of the resident/non-resident remitter)
for credit to the account of ____________ __________ __________ _____
(Name and address of non-resident) ___________ __________ ___________ ________ ___________
account holder stating country of residence and type of account) at ________ ________ ________
________ ________ ________ _______ ________ ________ ________ ______ ________ ________
__________
(Name of authorised dealer or authorised co-operative/commercial bank with whom account is kept)
Amount Rs._________________ _________________________________________________________
(in figures) (in words)
The purpose of payment is ___________ ____________ _________ ___
__________ ______________ ___________ ___________ __________ _________ ________________
For transfer* From the account of ____________ ____________ _____ ___
(Name and address of non-resident account holder stating country of residence and type of account)
at _________ _________ ________ ________ ________ ________ ________ ________ ________
________ ________ ________ ________ __________-
(Name of authorised dealer or authorised co-operative/commercial bank with whom account is kept)
for transfer to the account of __________ ____________ __________ _____
(Name and adddress of non-resident)
________ _________ ____________ ___________ ____________ _______
(account holder stating country of residence and type of account)
at ________ ________ ________ ________ ________ ________ ________ ________ ________
________ ________ ________ _________ _______________ __________________ _______________
(Name of authorised dealer or authorised co-operative/commercial bank with whom account is kept)
Amount Rs.________ _________ ________ __________ ________ ___________
(in figures) (in words)
The purpose of transfer is _________ ________ _______ _________ ________
__________ __________ __________ _________ _______ _________ ______
* Relevant part should be completed.
We certify that the above payment/transfer has been made in terms of the authority delegated to
authorised dealers or authorised co-operative/ commercial banks vide paragraph _________ of the
Exchange Control Manual / Memorandum ABM and/or A.D. Circular No. _____________.
(Signature of Authorised Official)
Name:
Designation:
Stamp
Name and Address
Date: of Authorised Dealer or
Authorised Co-operative/
Commercial Bank
(Space for comments of the authorised dealer or authorised co-operative/ commercial bank)
While forwarding the application to Reserve Bank for approval reference to paragraph of Exchange
Control Manual or Memorandum ABM or A.D. Circular in terms of which the reference is made should
invariably be cited.
Similar transaction was approved by Reserve Bank vide approval No.___________ dated
_______________
(Signature of Authorised Official)
Name:
Designation:
Stamp
Name and Address
Date: of Authorised Dealer or
Authorised Co-operative/
Commercial Bank
(Space for use by Reserve Bank of India)
