FORM A2 Revised Form

APPLICATION CUM FORM A2
TRANSACTIONS UNDER LIBERALISED REMITTANCE SCHEME

(Telegraphic Transfer (TT)/ Demand Draft (DD) /Foreign Currency Notes (CN))
To, AD CodeNo.
The Branch Head Branch D No.
Punjab National Bank
B/o
Sub: Application for drawl of Foreign Exchange

A. Details of theA licant:
■ ■
Name of the Applicant
Applicant's Customer ID
Applicant's Account Number
Address
Applicant Email ID and contact number
PAN No. ( Mandatory)
B. Details of Foreign Exchange drawl, Mode,Purpose and Source of Funds:
B(1)I / We request you to issue (Tick Mthe appropriatebox)
Telegraphic Transfer (TT)
Demand Draft (DD)

Foreign Currency Notes (CN)
Fill-up either B(2a) OR B (2b)

B (2a). For remittance of fixed amount of Foreign Currency
Foreign Currency
FC Amount in figures
FC Amount In words
OR
B (2b). For remittance of equivalent of Foreign Currency of Fixed Rupee Amount
Foreign Currency
INR Amount in figures
INR Amount In words
B (3). Purpose of Remittance with Purpose Group & Code (For details refer Appendix)
Purpose Purpose Whether under Purpose Description

Group ' Code LRS(YES/NO)
(1)
B (4).Country codeproviding ultimate services (if the purpose group No. is
02,03,05,06,07,08,09,10,11,15,16 or 17)
Name of the country
providing ultimate services:
B(5).Source of Funds
Source of funds
C. Beneficia Details:
Beneficiary's name and address
Beneficiary's Bank Name (in case of

Telegraphic Transfer)
Beneficiary's A/c Number (in case of

Beneficiary's Bank Address
including Country (in case of
SWIFTcode
IBAN
Intermediary Bank details (if applicable)
SWIFTcode
IBAN
Correspondent Bank charges borne [ ] Beneficiary(BEN)

by (select any one) [ ] Remitter(OUR) [
]Sharing(SHA)
0. The details of Forward Contract(s), if any, booked against this payment is/are as follows —
Forward Contract No. Forward Contract Amount to be Utilized Due Date of the
& Date Amount for this remittance Contract
E. I / We authorize you to debit my Saving AccountNo

with you for effecting remittance as detailed above at current market ratealong with your charges and
applicable government tax. I ensure that I will maintain sufficient balance in the account equivalent to
remittance amount plus bank charges. I understand that Bank shall not be liable for any consequences
(2)
B (4).Country codeproviding ultimate services (if the purpose group No. is
02,03,05,06,07,08,09,10,11,15,16 or 17)
Name of the country
providing ultimate services:
B(5).Source of Funds
Source of funds
C. Beneficia Details:
Beneficiary's name and address
Beneficiary's Bank Name (in case of

Beneficiary's A/c Number (in case of

Beneficiary's Bank Address
including Country (in case of
SWIFTcode
IBAN
Intermediary Bank details (if applicable)
SWIFTcode
IBAN
Correspondent Bank charges borne [ J Beneficiary(BEN)

by (select any one) [ ] Remitter(OUR) [
]Sharing(SHA)
D. The details of Forward Contract(s), if any, booked against this payment is/are as follows —
Forward Contract No. Forward Contract Amount to be Utilized Due Date of the
& Date Amount for this remittance Contract
E. I / We authorize you to debit my Saving AccountNo

with you for effecting remittance as detailed above at current market ratealong with your charges and
applicable government tax. I ensure that I will maintain sufficient balance in the account equivalent to
remittance amount plus bank charges. I understand that Bank shall not be liable for any consequences
(2)
arising out of the Bank's failure to carry out such instructions due to non maintenance of balance in the
account and I/WE shall be responsible to repay any loss incurred due to adverse fluctuation in the
currency rates with interest due to non maintenance of the sufficient balance in the account.
Declaration under FEMA 1999 as per Form A2:
I / We, (Name)
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 the Liberalized Remittance Scheme prescribed by the Reserve Bank of India i.e. USD
250,000/= (USD TWO HUNDERED FIFTY THOUSAND ONLY.) 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.
Details of the remittances made/transactions effected under the Liberalized Remittance

Scheme in the current financialyear(April to March ) is as follows:-
Sr. Date Amount in Purpose Name and address of AD branch through

No. Foreign which the transaction has been effected
Currency
Declaration by Applicant
I/VVe (Name) hereby declarethat-

1. I am a person resident in India.
2. I / We shall be responsible and liable for any incorrect detail provided by me /us.
3. I / We shall also hereby agree and undertake to give such information / documents as will reasonably
satisfy you about this transaction in terms of the abovedeclaration.
4. I have not availed any loan / credit / borrowings for remitting under Liberalized Remittance Scheme
for Capital Accounttransactions
5. The remittance is not being requested for any purpose specifically prohibited under Schedule I or any
item restricted under Schedule II of Foreign Exchange Management (Current Account Transaction)
Rules, 2000.
6. The remittance is not being requested for any transaction not permissible under FEMA and those in
the nature of remittance for margins or margin calls to overseas exchanges / overseas counter party
are not allowed under theScheme.
7. The remittance is not being sent directly or indirectly to Bhutan and Nepal or countries identified by
Financial Action Task Force (FATF) as non-co-operative countries and territories as available on
FATF website www.fatf-gafi.org. or as notified by the ReserveBank of India
8. The remittance is not being sent directly or indirectly to those individuals and entities identified as
posing significant risk of committing acts of terrorism as advised separately by the RBI to the banks.
9. The remittance is not being sent for purchase of FCCBs issued by Indian companies in the overseas
secondarymarket.
10. The remittance is not being sent for trading in foreign exchangeabroad.
(3)
11. In case of foreign remittance is for the purpose of Gift, I confirm that beneficiary is not a resident of
India.
Declaration-cum-undertaking under Sec 10(5), Chapter Ill of FEMA 1999, is

enclosed as under:
I / We hereby declare that the transaction details of which are mentioned above does not involve, and is
not designed for the purpose of any contravention or evasion of the provisions of the aforesaid Act, or of
any rule, regulation, notification, direction or order made there under.
I / We also understand that if I / we refuse to comply with any such requirement or make only
unsatisfactory compliance therewith, the Bank shall refuse, in writing, to understand the transaction and
shall, if it has reason to believe that any contravention / evasion is contemplated by me / us, report the
matter to Reserve Bank of India.
I / We also hereby agree and undertake to give such information / documents as will reasonably satisfy
you about this transaction, in terms of the above declaration.
Yours faithfully,
Signature of Applicant/Guardian
Account Number:
Date:
For office use, to be filled by bank official:
Certificate by the A D Branch
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 Liberalized Remittance Scheme.
Name and designation of the authorizedofficial:
Signature: Stamp andseal:
Date andPlace.
Appendix to Annexure I
Purpose Codes for Reporting under LRS
(4)
Purpose Name Group Purpose Description
Code
Capital Account 00 S0005 Purchase of Immovable Property

Transactions 00 S0001 Indian Portfolio investment abroad — in equity shares
00 S0002 Indian Portfolio investment abroad — in debt instruments
00 S0003 Indian Direct investment abroad (in branches & wholly owned
subsidiaries) in equity Shares
00 S0004 Indian Direct investment abroad (in subsidiaries and associates) in

debt instruments
00 S0021 Payments made on account of sale of share under Employee stock
option
00 S0022 Investment in Indian Depositories Receipts (IDRs)
00 S0023 Opening of foreign currency account abroad with a bank under LRS
Current Account 03 S0301 Business travel.

Transactions 03 S0303 Travel for pilgrimage
03 S0304 Travel for medical treatment
03 S0305 Travel for education (including fees, hostel expenses etc.)
03 S0306 Travel for Employment and Personal
13 S1301 Maintenance of Close Relatives
11 S1108 Medical Treatment
11 S1107 Studies Abroad
13 S1307 Emigration
00 S0011 Loans extended to Non-Residents close relative
06 S0603 Health Insurance
13 S1302 Gift
13 S1303 Donation
(5)

FORM A2 Revised Form

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APPLICATION CUM FORM A2

TRANSACTIONS UNDER LIBERALISED REMITTANCE SCHEME

Sub: Application for drawl of Foreign Exchange

Name of the Applicant

Applicant's Account Number

Applicant Email ID and contact number

PAN No. ( Mandatory)

B. Details of Foreign Exchange drawl, Mode,Purpose and Source of Funds:

B(1)I / We request you to issue (Tick Mthe appropriatebox)

Telegraphic Transfer (TT)

Demand Draft (DD)

Fill-up either B(2a) OR B (2b)

Purpose Purpose Whether under Purpose Description

Beneficiary's Bank Name (in case of

Beneficiary's A/c Number (in case of

Intermediary Bank details (if applicable)

Correspondent Bank charges borne [ ] Beneficiary(BEN)

E. I / We authorize you to debit my Saving AccountNo

Beneficiary's Bank Name (in case of

Beneficiary's A/c Number (in case of

Intermediary Bank details (if applicable)

Correspondent Bank charges borne [ J Beneficiary(BEN)

E. I / We authorize you to debit my Saving AccountNo

Declaration under FEMA 1999 as per Form A2:

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

Sr. Date Amount in Purpose Name and address of AD branch through

I/VVe (Name) hereby declarethat-

Declaration-cum-undertaking under Sec 10(5), Chapter Ill of FEMA 1999, is

For office use, to be filled by bank official:

Certificate by the A D Branch

Name and designation of the authorizedofficial:

Signature: Stamp andseal:

Purpose Codes for Reporting under LRS

Capital Account 00 S0005 Purchase of Immovable Property

00 S0004 Indian Direct investment abroad (in subsidiaries and associates) in

Current Account 03 S0301 Business travel.

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