Form A2 Cum LRS

AD CODE:
Office use only:

Remittance Ref. No.: Originating Branch
Code:
FCC Contract Ref. No.: Customer ID:
FORM A-2 CUM LRS DECLARATION
I/We ___________________________________________________________________
(Name of applicant remitter)
PAN No. ________________________________________________________________
Address_________________________________________________________________
authorize________________________________________________________________________
(Name of AD branch)
To debit my Savings Bank/ Current/ RFC/ EEFC A/c. No. ________________________
together with their charges and
* a) Issue a draft : Beneficiary's Name _____________________________________

Address ____________________________________
* b) Effect the foreign exchange remittance directly –

1) Beneficiary's Name _____________________________________
2) Name and address of the bank _____________________________________
3) Account No. _____________________________________
* c) Issue travelers cheques for _____________________________________
* d) Issue foreign currency notes for _____________________________________

Amount (specify currency) _____________________________________
* (Strike out whichever is not applicable) for the purpose/s indicated below
2) To be filled in by resident only if the remittance is made under LRS
Sr. No. Whether under LRS (Yes/No)* Purpose Code Description
Note – (*) If Yes under LRS, please submit additional details as per Appendix.
3) Payment for import of services (Purpose Group Nos. 02, 03, 05, 06, 07, 08, 09, 10, 11, 15,
16 or 17), please indicate:
“Name of the country providing ultimate services:…………………”
(Remitter should put a tick (√) against an appropriate purpose code. In case of doubt/
difficulty, the AD bank should be consulted).
Declaration
(Under FEMA 1999)
1. I/We ……………………………….. (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 as per the extant FEMA Regulations 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/ Foreign exchange purchased from you is for the
purpose indicated above.
Details of the remittances made/transactions effected under the Liberalised 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
Signature of the Applicant
(Name)
Date:
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 of India from
time to time under the Scheme.
Name and designation of the authorised official:
Stamp and seal
Signature
Date:
APPENDIX
(To be submitted only in case of LRS)
OUTWARD REMITTANCE APPLICATION FOR RESIDENT INDIVIDUALS

(To be completed by the applicant IN BLOCK LETTERS)
I. DETAILS OF THE APPLICANT (REMITTER)

Customer ID: Account Number:
Branch Name: DP Code:
NAME OF THE
APPLICANT
FULL ADDRESS
TEL. NO. MOB. NO.

CONTACT DETAILS E-MAIL
PAN NUMBER
II. DETAILS OF THE FOREIGN EXCHANGE REQUIRED (Choose applicable option A or B or C)
A. For remittance of fixed amount of Foreign Currency
Foreign Currency FC
Amount
in Words
FC Amount in Figures
B. For remittance in Foreign Currency equivalent of Fixed Rupee Amount
Foreign Currency INR

Amount
in Words
INR Amount in Figures
C. For remittance in Foreign Currency other than above
Foreign Currency FC
Amount
in Words
FC Amount in Figures
(Signature of the Applicant)
(CONT …2)
III. ACCOUNT DETAILS TO BE DEBITED
ACCOUNT NUMBER ACCOUNT TYPE AMOUNT IN FOREIGN CURRENCY
IV. PURPOSE OF REMITTANCE WITH PURPOSE CODE

SL PURPOSE FETERS SL PURPOSE FETERS
CODE CODE
1 INVESTMENT ABROAD IN Equity Capital S0001 6 TRAVEL Business S0301
(shares)
[Portfolio
Investment]
Debt Instruments S0002 Pilgrimage S0303
[Portfolio
Investment]
Indian Direct S0003* Medical S0304
investment Treatment
abroad in equity Education(Incl. S0305
shares* Fee, Hostel Exp
etc)
ESOP S0021 Other Travels S0306
IDRs S0022 including
Holiday Trip,
Settlement of
International
Credit Cards
2 PERSONAL GIFT AND S1302 7 HEALTH Medical S1108
DONATIONS SERVICES Treatment
3 DONATIONS TO S1303 8 STUDIES Education (E.g. S1107
RELEGIOUS & ABROAD fees for
CHARITABLE correspondence
INSTITUTIONS courses abroad)
4 MAINTENANCE OF S1301 9 EMIGRATION S1307
CLOSE RELATIVE
5 OPENING OF FOREIGN S0023 Loan to NRI S0011
CURRENCY ACCOUNT Close Relative
ABROAD
6 PURCHASE OF S0005 General S0603
OTHERS
IMMOVABLE PROPERTY 10 Insurance
ABROAD Premium and
Term Life
Insurance
Premium
PURPOSE: FETERS CODE:
SOURCE OF FUNDS
(*) – ODI form Part-I to be submitted along with this form.
(CONT …3)
If the purpose selected is one of the below then it is mandatory to furnish the details sought for
MAINTENANCE OF CLOSE Relationship of beneficiary

RELATIVE
Student Name and Student ID.
EDUCATION Country of study abroad
The location of property being STATE:
PURCHASE OF IMMOVABLE purchased
PROPORTY ABROAD (#) COUNTRY:
Equity Shares, Mutual Funds, VC

INVESTMENT ABROAD (#) Fund NAME OF THE COMPANY :
Debt Instrument
LISTED / UN –LISTED:
Others: (Furnish details) UIN NO.

(#) – If eligibility of more than one individual is clubbed, investment should be in joint names.
V. NATURE OF INSTRUMENT (SELECT THE MODE OF PAYMENT- TICK MARK)

WIRE FOREIGN
DEMAND TRAVELERS ISSUE TRAVEL CARD
TRANSFER CURRENCY
DRAFT CHEQUE / RE-LOAD
SWIFT NOTES
VI. DETAILS OF THE BENEFICIARY

BENEFICIARY NAME *
BENEFICIARY FULL ADDRESS *
ACCOUNT NUMBER *
IBAN*
(Compulsory for remittance to UK, Europe,
Gulf countries and other countries
implemented IBAN)
BSB * : ( For Australia)
TRANSIT CODE* : ( For Canada)
BENEFICIARY BANK NAME & ADDRESS*
SWIFT /BIC
SWIFT / BIC OF INTERMEDIARY BANK, IF ANY
&
BENEFICIARY BANK ACCOUNT NO. WITH
INTERMEDIARY BANK
(* Mandatory for WIRE transfer through SWIFT)
(CONT …4)
VII. DETAILS OF THE REMITTANCE MADE/TRANSACTIONS EFFECTED UNDER THE SCHEME IN THE
CURRENT FINANCIAL YEAR (APRIL- MARCH) _________________
SL NAME & ADDRESS OF AD BRANCH /FFMC THROUGH
DATE CURRENCY AMOUNT
NO. WHICH THE TRANSACTION HAS BEEN EFFECTED
1
2
3
TOTAL (EQUI. IN USD)
VIII. DETAILS OF FORWARD CONTRACT BOOKED TO BE UTILIZED FOR THIS TRANSACTION
Rate Covered IF ANY with our Trader, please mention the details below:
(Applicable only for the Day)
……………………………………………………………………………………………………………….
This is to authorize you to debit my/our above mentioned account together with all charges & taxes
and affect the foreign exchange remittance through SWIFT / issue Demand Draft /TCs / FCNs/ Issue
or Reload of Travel Card as detailed above. (Strike out whichever is not applicable).

Form A2 Cum LRS

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Form A2 Cum LRS

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Copyright:

Available Formats

AD CODE:

Office use only:

FORM A-2 CUM LRS DECLARATION

* a) Issue a draft : Beneficiary's Name _____________________________________

* b) Effect the foreign exchange remittance directly –

* c) Issue travelers cheques for _____________________________________

* d) Issue foreign currency notes for _____________________________________

2) To be filled in by resident only if the remittance is made under LRS

Sr. No. Whether under LRS (Yes/No)* Purpose Code Description

“Name of the country providing ultimate services:…………………”

Details of the remittances made/transactions effected under the Liberalised Remittance

Sr. No. Date Amount Name and address of AD branch/FFMC through

Signature of the Applicant

Certificate by the Authorised Dealer

Name and designation of the authorised official:

Stamp and seal

OUTWARD REMITTANCE APPLICATION FOR RESIDENT INDIVIDUALS

I. DETAILS OF THE APPLICANT (REMITTER)

TEL. NO. MOB. NO.

II. DETAILS OF THE FOREIGN EXCHANGE REQUIRED (Choose applicable option A or B or C)

A. For remittance of fixed amount of Foreign Currency

B. For remittance in Foreign Currency equivalent of Fixed Rupee Amount

Foreign Currency INR

C. For remittance in Foreign Currency other than above

(Signature of the Applicant)

ACCOUNT NUMBER ACCOUNT TYPE AMOUNT IN FOREIGN CURRENCY

IV. PURPOSE OF REMITTANCE WITH PURPOSE CODE

PURPOSE: FETERS CODE:

MAINTENANCE OF CLOSE Relationship of beneficiary

Equity Shares, Mutual Funds, VC

Others: (Furnish details) UIN NO.

V. NATURE OF INSTRUMENT (SELECT THE MODE OF PAYMENT- TICK MARK)

VI. DETAILS OF THE BENEFICIARY

BENEFICIARY FULL ADDRESS *

BENEFICIARY BANK NAME & ADDRESS*

VIII. DETAILS OF FORWARD CONTRACT BOOKED TO BE UTILIZED FOR THIS TRANSACTION

(Signature of the Applicant)

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