kotak FORM - A2 AND APPLICATION-CUM-DECLARATION Redcar nner (FOR PAYMENTS OTHER THAN IMPORTS AND REMITTANCE COVERING INTERMEDIARY TRADE) (ieee ir nse ere tart cee) MY DETAILS 1 Mc CMs Name (FestName) (Wide Ware} Address ay Pin Code state Comey CRN PAN No. (andatoy) authorise Kotak Mahindra Bank to Debit my Saving Bank/Curren/RFCIEEFC Tiame of hatred Dear Bored ‘Account Number ‘together with processing charges, GST on foreign currency coversions and correspondent bank charges. Refer our website www.kotak.com for details of charges My Residential Status [" Resident in india Foreign National Resident in India DETAILS OF FOREIGN EXCHANGE REQUIIRED Amount of Remittance: Foreign Currency (FCY) Amount: Amount inwords =| Purpose of Remittanc Purpose Code: (Us of Purpose Codes and Descipons povided as Annenut) "confi thatthe benefiday ofthis eiance isnot a person resident in India (Indian Organization in case beneficiary is Nonndvidual) as dined under Foregn Exchange Managernent Act, 1988 (To be contmed if purpose code selected is *Gi") Signature of Applicant: Source of Funds: (wandazoy) | Education Loan |_| Others (Specify) Mode of Remittance [FCY Currency| Amount. Passport Details (if applicable) Telegraphic Transfer (1) Passport Number Cash Date and Place of issue 8 Draft Valid Upto 3 Bearer of charges* 8 Remitter (OUR) Beneficiary (BEN/SHA) S ‘eae of charges is selected as Reiter: the compete remittance arount wil be crested to beneficiary's bank. bearer of charges is slected as Benet he net amount of emitanc ae deducing coresponden bank hage) willbe credited o benefits bank etal charges wil be considered as Boe by benefiay incase information ‘sot provided = DETAILS OF THE BENEFICIARY Beneficiary Details Name Berefidary Account No, tiny Adress Relationship ofthe Applicant with the Benefidary pr a Receiving Bank Bark Name Branch Bank Ades SWIFT 1 of Bank CHIPS UIDIFEDWRE Routing No,SortCodellBAN/BSB No.Tansit No. Intermediary Bank Intermediary Bark Name Branch Bark Ades ST 1 of Bank (CHIPS UIDIFZDWIRE Rong Ne Sor Code BANIBSB No ans No, ‘Adaltional Information IN CASE OF FOREIGN CURRENCY DEMAND DRAFT (FCY DD) Please hold, | will collect Please handover to the bearer whose signature is attested herewith Bearer’s Signature = Collected tested by meDECLARATION. 1 (Name) hereby declare that the total amount of Foreign Exchange purchased or remitted through all sources tn India during the Financial Year (Aprl-March) as per the details mentioned in the Application, including loan extended or gift made in Rupees credited to NRO Account of Non-Resident Individual Close Relative(s) and FCY transaction(s) using Debit Card(), is within th limit of USD (USDolars Oniy), whichis the limit prescribed by the Reserve Bank of India (RBI). | further certify thatthe source of funds for making the said remittance belongs tome and willnotbe used for prohibited purposes. Details ofthe Remittances made/transactions effected under the Liberalsed Remittance Scheme in the Current Financial Year (Apri March) S.No] Date | Amount Name and Address of AD Branch through which the transaction has been effected urther declare and confirm that 1, Remittance is not for any prohibited or illegal activities such as margin trading, lottery etc, 2. Remittance is not for margin or margin calls to overseas exchangesioverseas counterparty, 3. Remittance is not for purchase of FCCBs issued by Indian companies in the overseas secondary marl. 4, Remittances is not for trading in Foreign Exchange Abroad. 5. Foreign Exchange purchased from you is for the purpose indicated in the form, | dectare and confirm that (applicable only ifthe remittance is to the account maintained with any Intemational Financial Service Centres (IFSC) any funds lying idle in the account for a period upto 15 days from the date of its receipt into the account shall be immediately repatriated to domestic INR account of the investor in India Without any ris, responsibilty or lability to yourself and subject to the Terms & Conditions outlined on your website wwwwzkotak.com which Ihave read and understood, please effect the remittance as per the details mentioned overleat understand thatthe bank has accepted this LRS transaction request basis my declaration and affirmation that | have not utilised my LRS transaction limit of USD 2,50,000 for current FY through KMBL or any other Bank. | understand, confirm and agree that in case it is identified from the RBI database or any other proper source that there is no ot insufficient LRS limits available to process the transaction, the bank shall be at liberty to Toject / reverse the transaction. Exchange los, if any, due to cancellation of transaction will be debited to my account. Date: aa Signature of the Remitter Place: CERTIFICATE BY THE AUTHORISED DEALER This s 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 of India from time-to-time under the LRS Scheme. Name and Designation of the Authorised Official Signature ‘Stamp and Seal ofthe AD Branch Date: sl) Place: FOR BANK USE AD Code Number Form Number (Tobe filed by the Authorised Dea) Serial Number FCY Amount (For use af the Reserve Bank of indi) Currency Equivalent to® (Tobe debited frm Ne) (Tobe completed by the tuthorsed Dealer Transaction Ret. No. Conversion Rate Branch Instrument No.(s) Date: Made by: ‘Authorised by: rare ot rere KMBL\May-2021\V1-08UNS eu elt ae) ) FOR PAYMENTS UNDER LIBERALIZED REMITTANCE SCHEME (LRS) Gr] Purpose [Purpose No.| GroupName | Code Cea 0 Financial Account Foreign $0001 | Indian Portfolio investment abroad — in equity shares Portfolio " Investments $0002 | Indian Portfolio investment abroad — in debt instruments Foreign Direct 50003 | Indian Direct investment abroad (in branches & Investments wholly owned subsidiaries) in equity Shares Indian Direct investment abroad (in subsidiaries and 50004 | associates) in debt instruments $0005 | Indian investment abroad — in real estate External Commercial 0011 | Loans extended to Non-Residents Borrowings Financial 0021 | Payments made on account of sale of share under Derivatives and Employee Stock Option Others $0022 | Investment in Indian Depositories Receipts (IDRs) $0023 | Opening of foreign currency account abroad with a bank $0301 | Business travel 3. travel $0303 | Travel for pilgrimage $0304 | Travel for medical treatment $0305 | Travel for education (including fees, hostel expenses etc.) 50306 | ther travel (including holiday trips and payments for settling International Credit Cards transactions) 6 Insurance and 50603 | Other General Insurance Premium including Reinsurance Pension Service Premium and Term Life Insurance Premium, 11 Personal, $1107 | Education (e.g. fees for correspondence courses abroad) Cultural & Recreational Health Service (payment towards services received from services $1108 | hospitals, doctors, nurses, paramedical and similar services etc. rendered remotely or on-site) 13 [Secondary $1301 _| Remittance for family maintenance and savings Income $1302 | Remittance towards personal gifts and donations 51303 | Remittance towards donations to religious and charitable institutions abroad Outflows on account of migrant transfers including personal effects $1307