Form A2 – Application cum Declaration

(To be completed by the applicant)

I. Details of the applicant (Remitter) -

Name :
Address :

Date of Birth : Nationality :

Mobile No : Email id :

Aadhaar ID : Passport No : Date of Expiry :

II. Details of Foreign Exchange required (Currency Code & Amount)

Currency Notes Prepaid Card Trav. Cheques Out Remit(TT) FCY Drafts

III. Travel Details

Place of Travel : Date of Travel : Duration (in Days) :

Purpose of Visit : Ticket Number :

IV. Details of the Student (For Outward Remittance & FC Demand Draft)

Name of the Student :

Student Id : Name of University :

V. Outward Remittance - Beneficiary Details

Beneficiary Name :
Beneficiary Address :
Beneficiary Account No :
Bank Name :
Bank Address :
IBAN No :
SWIFT CODE :
ABA Routing / BSB/Sort Code/ Fed Wire :
Correspondent Bank Charges : To be paid bytheBeneficiary To be paid by theRemitter

VI. Foreign Demand Draft

Beneficiary Name : Country :

VII. Payment Details

Payer PAN Number : Payer Name :
OwnFunds Others For others, Specify relationship :
Source Of Funds
Bank Demand CC/
Cash Cheque Transfer Draft DC
Payer Bank Name & Instrument Details
Branch Name
Payer account no : Payer Bank IFSC code :
**In Case where account details are not reflected in payment details then cancelled cheque or bank statement need to be
provided as account details proof
** Only Closed Relatives as per section VI of Companies Act are permitted in the case of remittance which are related to
each other as Husband and wife, if they are members of HUF or they are related to each other as Father (including step
Father), Mother (including step Mother), Brother (including step Brother), Sister (including step Sister), Son (including step
son), Son’s wife, Daughter (including step Daughter), Daughter’s husband.

Declaration cum undertaking

1. I, 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 USD 250,000/- (USD Dollar Two Hundred and Fifty Thousand Only) which is the limit
prescribed by the Reserve Bank of India for the said purpose and certify that the source of funds for making the said remittance belong to me and
the foreign exchange shall not be used for prohibited purposes. The transaction details of which are mentioned above does not involve, and is not
designed for the purpose of any contradiction or evasion of the provisions of the FEMA 1999 or of any Rule, Regulation, Notification, Direction or
Order made there under. I also hereby agree and undertake to provide such information / documents as will reasonable satisfy you about this
transaction in terms of thisdeclaration.

I, undertake that in case, if it is reported that I have breached the LRS limit, I will be my responsibility to bring back/surrender the amount
purchased/remitted in excess of the LRS limit and thereafter I will approach RBI for compounding of contravention under FEMA 1999.

Details of the remittances made /transactions effected under the Liberalized Remittance Scheme in the current financial year (April – March)

Sr No. Date Amount Name and Address of AD branch/ FFMC through which the transaction has been effected

2. I/We have / have not done LRS transaction from other Bank/ Forex issuing authorized agency or breached the ₹ 7 lakhs limit for the fiscal year
earlier with other Bank/Forex issuing authorized agency.

3. I am a foreign national permanently resident in India and that I am not availing facilities for remittance out of my salary, savings etc abroad in
terms of existing exchange control regulation (Applicable for Foreign Nationalsonly)

4. I am a foreign national permanently resident in India and that I am not availing facilities for remittance out of my salary, savings etc abroad in
terms of existing exchange control regulation (Applicable for Foreign Nationalsonly)

5. I shall be responsible and liable for any incorrect information provided by me in the formabove.

6. I further agree that in the event transaction is cancelled or revoked by me after submitting the request, any exchange losses incurred in this
connection to be recovered from the refundamount.

7. I further agree that once the funds remitted by me have been transmitted by Wall Street Finance Ltd (through AD Bank) to the correspondent
and/or beneficiary banks, Wall Street Finance Ltd shall not be responsible for any delays in the disbursement of such funds including the
withholding of such funds by the correspondent and/or beneficiary bank. I agree that once the funds are remitted, intermediary bank charges may
be levied by the correspondent and/or beneficiary banks, which may vary from bank to bank. I agree that in the event the transaction is rejected by
the correspondent and/or beneficiary bank because of incorrect information submitted by me, any charges levied by the
beneficiarybankorexchange lossesincurredinthisconnection,Iwill be liabletopaythesametoWallStreetFinanceLtd.

8. I further confirm that the foreign exchange released for the above mentioned purpose will be used within 180 days of purchase. In case it is not
possible to use within 180 days, same will be surrendered to the authorized person. I am neither a Politically Exposed Person (PEP) nor related to
anyPEP’s.

9. *I also confirm that this foreign exchange will only be use for paying my University fees and overseas education expense only. *applicable only
for student going for overseas education.

Signature of the Applicant Date

To be filled in by Authorized Dealer)

AD Code No.: AD Cat II - 02/2006 Currency : Equivalent to Rs :
Form No : Amount :

GR. No. Purpose Group Purpose Code Description

2 Travel S0301 Business travel.

S0303 Travel for pilgrimage

S0304 Travel for medical treatment

S0305 Travel for education (including fees, hostel expenses etc.)

S0306 Other travel (including holiday trips)

Signature of Branch Official

Branch Location & Stamp