A2 CUM APPLICATION FORM FOR FOREIGN

EXCHANGE PAYMENTS OVERSEAS UNDER LRS

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

Applicant Name :
Applicant Address :

PAN No CIF ID
Details of Foreign Exchange Required
A. Remittance Yes No Currency Type Amount in FCY
B. Forex Card Yes No Purpose Code and Description
C. FCY Cash Yes No Travel Destination Source of Fund: Own Fund Family Fund Loan
Payment Details
I/We authorize RBL Bank to debit my account: RBL Account No: to process the foreign currency
remittance / issue DD / FCY Notes / Forex Card as instructed including government levies and bank charges.
Payment Details For Non-RBL Bank Account Holders
Type of Payment Instrument: RTGS NEFT IMPS Cheque UTR No / Cheque No.
BENEFICIARY DETAILS

Beneficiary Name FIRST MIDDLE LAST

Residential Status of the Beneficiary: Indian Resident NRI OCI

Beneficiary Address

Beneficiary Bank Name

Beneficiary Bank
Address
Account Number Swift Code IBAN Number Routing No.

BSB/Sort Code/Transit No Student ID/REF. No. (if required)

Student's Name FIRST MIDDLE LAST
INTERMEDIARY BANK (if any)
Bank Name
Bank Address

Account Number 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 immediate financial year including this application is within the overall limit of USD 250,000/-(US Dollar Two hundred and Fifty Thousand
only) under the Liberalized Remittance Scheme (LRS) prescribed by the Reserve Bank of India and certify that the source of funds is as declared above
and the foreign exchange will not be used for prohibited purposes as defined in law and FEMA Further, I Declare that the transaction mentioned above
does not involve, and is not designed for any purpose for which the drawing of foreign exchange is prohibited under rule 3 of the FEMA Current A/c
transactions Rules, 2000
Declare that the transaction mentioned above does not involve, and is not designed for any purpose related to end use like investment/purchase/
trading/commission/sale/proceeds/redemption/repatriation of Crypto currencies / Virtual Currencies / mutual funds or shares or any other instrument
including capital instrument of a company dealing in Crypto currencies / Virtual Currencies, further The source of funds for the proposed Remittance is
NOT proceeds from redemption of investment in Cryptocurrency /Bitcoins/Virtual Currencies and also end use of.
I / We, being a person(s) resident in India, hereby declare that for transactions done under the LRS for resident individuals, issued and amended by RBI
from time to time, is not in the nature of remittance for margin or margin calls to overseas exchanges / overseas counter parties under this scheme.
In case the remittance is made under purpose of Investment in shares, I / we confirm that the remittance is towards Investment in Equity and not for
trading in forex or any other margin-based trading or any other purpose prohibited as per the terms and conditions of the LRS for resident Individuals.
Further, I / we, confirm that the remittance is not for lottery / margin trading or illegal activities and not for FCCBs issued by Indian Company/ies for
trading in secondary market.
Agree and undertake to give such information / documents as will reasonably satisfy you about this transaction in terms of the above declaration as and
when called for by RBL Bank
I Understand that if I/We refuse to comply with any such requirement or make any unsatisfactory compliance herewith, if RBL Bank has reason to believe
that my contravention / evasion is contemplated by me / us the bank reserves the right to refuse the transaction including report the matter to Reserve
Bank of India

LRS-A2/21112023/Ver 2.0
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.

Details of all foreign currency remittances under LRS done by you in this Financial Year April-March (20__-20__) excluding RBL Bank
Sr. No. Date Amount (in INR) Name and Address of AD Branch / FFMC through which the transaction has been effected

Please add a separate sheet for more transactions.

Date: D D M M Y Y Y Y
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.
Amount in INR Exchange Rate
Date: D D M M Y Y Y Y Branch Name and Code
Name and Designation of Authorised Person Signature & Stamp

GR No. Purpose Group Name Purpose Code Purpose Description

Financial Account
S0001 Indian investment abroad -in equity capital (shares)
Foreign Portfolio investments
S0002 Indian investment abroad -in debt securities
Indian Direct Investment abroad (in branches and wholly owned subsidiaries) in
S0003
equity shares
Foreign Direct Investments Indian Direct Investment abroad (in subsidiaries and associates) in debt instru-
0 S0004
ments
S0005 Indian Investment abroad - in real estate
External Commercial Borrowing S0011 Loans extended to non-residents
S0021 Payments made on account of sale of share under Employee
Financial Derivatives and Others S0022 Investment in Indian Depositories Receipts (IDRs)
S0023 Opening of a foreign currency account abroad with a bank
S0301 Business Travel
S0303 Travel for Pilgrimage
S0304 Travel for medical treatment
3 Travel
S0305 Travel for education (incl. fees, hostel expenses, etc.)
Other Travel (holiday trips and payments for settling international credit card trans-
S0306
actions)
6 Insurance and Pension service S0603
S1107 Education (e.g., fees for correspondence courses abroad)
11 Personal, Cultural and recreational services Health service (payment towards services received from hospitals, doctors, nurses,
S1108
paramedical and similar services, etc. rendered remotely on-site)
S1301 Remittance for family maintenance and savings
S1302 Remittance towards personal gifts and donation
13 Secondary income
S1303 Remittance towards donations to religious and charitable institutions abroad
S1307 Outflows on account of migrant transfers including personal effects

LRS-A2/21112023/Ver 2.0