15

Annex
FORM A2
(To be completed by the applicant)

AD Code No.__________________________
(For payments other Form No._____________________________
than imports and (To be filled in by the Authorised Dealer)
remittances covering
intermediary trade)
USD Amount ___Equivalent to Rs. ____
Currency_____
Application for (To be completed by the Authorised Dealer)
Remittance Abroad
Kartik Verma
I/We _____________________________________________________________
(Name of applicant remitter)
PAN No. __________________________________________________________
BRPPV0341E

tinsukia commerce college road, near D.R.M colony dhakiajuri bongali gaon, west sripuria, Dhekiajuri Bongali Gaon, Tinsukia
Address___________________________________________________________

authorize
__________________________________________________________________
(Name of AD branch)(Address of AD branch)
To debit my Savings Bank/ Current/ RFC/ EEFC A/c. No. ____________________
38915851872

together with their charges and

* a) Issue a draft : Beneficiary's Name __Apex Clearing___________________

Address __350 N St. Paul Street, Suite 1300, Dallas, TX 75201____

* b) Effect the foreign exchange remittance directly –

1) Beneficiary's Name __Apex Clearing ____________________
2) Name and address of the bank __ N_
am__
e:_BMO Harris Bank, __
Add_r_es_s_:_111 W Monroe
St, Chicago, IL 60603
3) Account No. _3713286 ____ __F_T_C
SWI _O__D_E:___HATRUS44 __

* 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

Sr. Whether under LRS Purpose Code Description

No. (Yes/No) Indian portfolio investment abroad -
Yes S0001 in equity shares
As per the Annex

(Remitter should put a tick (√ ) against an appropriate purpose code. In case of doubt/
difficulty, the AD bank should be consulted).

15
Inserted vide AP (Dir) series Circular 50 dated February 11, 2016. Prior to insertion it read as Annex 1, which has since
been replaced with effect from the same date.
16
Modified vide AP (DIR) Series Circular No. 32 dated June 19, 2018. Prior to modification, it read “PAN No. (For
remittances exceeding USD 25,000 and for all capital account transactions)”

12
 Declaration
(Under FEMA 1999)
Kartik Verma
1. # I, ………………. …………(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 within the overall limit of the Liberalised Remittance
Scheme prescribed by the Reserve Bank of India 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 Liberalised

Remittance Scheme in the current financial year (April- March) ..…
Sl. Date Amount Name and address of AD branch/FFMC through which
List No the transaction has been effected
previous
remittances
if applicable
2. # The total amount of foreign exchange purchased from or remitted through, all
sources in India during this calendar year including this application is within USD
_______________________ (USD __250000__________) the annual limit
prescribed by Reserve Bank of India for the said purpose.

3. # Foreign exchange purchased from you is for the purpose indicated above.

# (Strike out whichever is not applicable )

Signature of the applicant

(Name) Kartik Verma

Date: 30/06/2021

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.

Name and designation of the authorised official:

Stamp and seal

Signature:

Date:

Place:

13
 Purpose Codes for Reporting under FETERS

A. Payment Purposes (for use in BOP file)

Gr. No. Purpose Group Purpose Description

Name Code

00 Capital Account S0017 Acquisition of non-produced non-financial assets (Purchase of intangible

assets like patents, copyrights, trademarks etc., land acquired by
government, use of natural resources) – Government
S0019 Acquisition of non-produced non-financial assets (Purchase of intangible
assets like patents, copyrights, trademarks etc., use of natural
resources) – Non-Government
S0026 Capital transfers ( Guarantees payments, Investment Grand given by
the government/international organisation, exceptionally large Non-life
insurance claims) – Government
S0027 Capital transfers ( Guarantees payments, Investment Grand given by
the Non-government, exceptionally large Non-life insurance claims) –
Non-Government
S0099 Other capital payments not included elsewhere
Financial Account
Foreign Direct S0003 Indian Direct investment abroad (in branches & wholly owned
Investments subsidiaries) in equity Shares
S0004 Indian Direct investment abroad (in subsidiaries and associates) in debt
instruments
S0005 Indian investment abroad – in real estate
S0006 Repatriation of Foreign Direct Investment made by overseas Investors in
India – in equity shares
S0007 Repatriation of Foreign Direct Investment in made by overseas Investors
India – in debt instruments
S0008 Repatriation of Foreign Direct Investment made by overseas Investors in
India – in real estate
Foreign Portfolio S0001 Indian Portfolio investment abroad – in equity shares
Investments S0002 Indian Portfolio investment abroad – in debt instruments
S0009 Repatriation of Foreign Portfolio Investment made by overseas Investors
in India – in equity shares
S0010 Repatriation of Foreign Portfolio Investment made by overseas Investors
in India – in debt instruments
External S0011 Loans extended to Non-Residents
Commercial S0012 Repayment of long & medium term loans with original maturity above
Borrowings one year received from Non-Residents
Short term S0013 Repayment of short term loans with original maturity up to one year
Loans received from Non-Residents
Banking Capital S0014 Repatriation of Non-Resident Deposits (FCNR(B)/NR(E)RA etc)
S0015 Repayment of loans & overdrafts taken by ADs on their own account.
S0016 Sale of a foreign currency against another foreign currency
Financial S0020 Payments made on account of margin payments, premium payment and
Derivatives and settlement amount etc. under Financial derivative transactions.
Others S0021 Payments made on account of sale of share under Employee stock
option
S0022 Investment in Indian Depositories Receipts (IDRs)

14
Gr. No. Purpose Group Purpose Description
Name Code

S0023 Opening of foreign currency account abroad with a bank

External S0024 External Assistance extended by India. e.g. Loans and advances
Assistance extended by India to Foreign governments under various agreements
S0025 Repayments made on account of External Assistance received by India.

01 Imports S0101 Advance payment against imports made to countries other than Nepal
and Bhutan
S0102 Payment towards imports- settlement of invoice other than Nepal and
Bhutan
S0103 Imports by diplomatic missions other than Nepal and Bhutan
S0104 Intermediary trade/transit trade, i.e., third country export passing through
India
S0108 Goods acquired under merchanting / Payment against import leg of
merchanting trade*
S0109 Payments made for Imports from Nepal and Bhutan, if any
02 Transport S0201 Payments for surplus freight/passenger fare by foreign shipping
companies operating in India
S0202 Payment for operating expenses of Indian shipping companies operating
abroad
S0203 Freight on imports – Shipping companies
S0204 Freight on exports – Shipping companies
S0205 Operational leasing/Rental of Vessels (with crew) –Shipping companies

S0206 Booking of passages abroad – Shipping companies

S0207 Payments for surplus freight/passenger fare by foreign Airlines
companies operating in India
S0208 Operating expenses of Indian Airlines companies operating abroad
S0209 Freight on imports – Airlines companies
S0210 Freight on exports – Airlines companies
S0211 Operational leasing / Rental of Vessels (with crew) – Airline companies
S0212 Booking of passages abroad – Airlines companies
S0214 Payments on account of stevedoring, demurrage, port handling charges
etc.(Shipping companies)
S0215 Payments on account of stevedoring, demurrage, port handling charges,
etc.(Airlines companies)
S0216 Payments for Passenger - Shipping companies
S0217 Other payments by Shipping companies
S0218 Payments for Passenger - Airlines companies
S0219 Other Payments by Airlines companies
S0220 Payments on account of freight under other modes of transport (Internal
Waterways, Roadways, Railways, Pipeline transports and others)
S0221 Payments on account of passenger fare under other modes of transport
(Internal Waterways, Roadways, Railways, Pipeline transports and
others)
S0222 Postal & Courier services by Air
S0223 Postal & Courier services by Sea

15
Gr. No. Purpose Group Purpose Description
Name Code

S0224 Postal & Courier services by others

03 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 and payments for settling
international credit cards transactions)
05 Construction S0501 Construction of projects abroad by Indian companies including import of
Services goods at project site abroad
S0502 Cost of construction etc. of projects executed by foreign companies in
India.
06 Insurance and S0601 Life Insurance premium except term insurance
Pension Services S0602 Freight insurance – relating to import & export of goods
S0603 Other general insurance premium including reinsurance premium; and
term life insurance premium
S0605 Auxiliary services including commission on insurance
S0607 Insurance claim Settlement of non-life insurance; and life insurance
(only term insurance)
S0608 Life Insurance Claim Settlements
S0609 Standardised guarantee services
S0610 Premium for pension funds
S0611 Periodic pension entitlements e.g. monthly quarterly or yearly payments
of pension amounts by Indian Pension Fund Companies.
S0612 Invoking of standardised guarantees
07 Financial Services S0701 Financial intermediation, except investment banking - Bank charges,
collection charges, LC charges etc.
S0702 Investment banking – brokerage, under writing commission etc.
S0703 Auxiliary services – charges on operation & regulatory fees, custodial
services, depository services etc.
08 Telecommunicatio S0801 Hardware consultancy/implementation
n, Computer & S0802 Software consultancy / implementation
Information
Services S0803 Data base, data processing charges
S0804 Repair and maintenance of computer and software
S0805 News agency services
S0806 Other information services- Subscription to newspapers, periodicals
S0807 Off-site software imports
S0808 Telecommunication services including electronic mail services and voice
mail services
S0809 Satellite services including space shuttle and rockets etc.
09 Charges for the S0901 Franchises services
use of S0902 Payment for use, through licensing arrangements, of produced originals
intellectual or prototypes (such as manuscripts and films), patents, copyrights,
property (not trademarks and industrial processes etc.
included elsewhere)
10 Other Business S1002 Trade related services – commission on exports / imports
Services

16
Gr. No. Purpose Group Purpose Description
Name Code

S1003 Operational leasing services (other than financial leasing) without

operating crew, including charter hire- Airlines companies
S1004 Legal services
S1005 Accounting, auditing, book-keeping services
S1006 Business and management consultancy and public relations services
S1007 Advertising, trade fair service
S1008 Research & Development services
S1009 Architectural services
S1010 Agricultural services like protection against insects & disease, increasing
of harvest yields, forestry services.
S1011 Payments for maintenance of offices abroad
S1013 Environmental Services
S1014 Engineering Services
S1015 Tax consulting services
S1016 Market research and public opinion polling service
S1017 Publishing and printing services
S1018 Mining services like on–site processing services analysis of ores etc.
S1020 Commission agent services
S1021 Wholesale and retailing trade services.
S1022 Operational leasing services (other than financial leasing) without
operating crew, including charter hire- Shipping companies
S1023 Other Technical Services including scientific/space services.
S1099 Other services not included elsewhere
11 Personal, Cultural S1101 Audio-visual and related services like Motion picture and video tape
& production, distribution and projection services.
Recreational S1103 Radio and television production, distribution and transmission services
services
S1104 Entertainment services
S1105 Museums, library and archival services
S1106 Recreation and sporting activities services
S1107 Education (e.g. fees for correspondence courses abroad )
S1108 Health Service (payment towards services received from hospitals,
doctors, nurses, paramedical and similar services etc. rendered
remotely or on-site)
S1109 Other Personal, Cultural & Recreational services
12 Govt. not S1201 Maintenance of Indian embassies abroad
included S1202 Remittances by foreign embassies in India
elsewhere
13 Secondary S1301 Remittance for family maintenance and savings
Income S1302 Remittance towards personal gifts and donations
S1303 Remittance towards donations to religious and charitable institutions
abroad
S1304 Remittance towards grants and donations to other governments and
charitable institutions established by the governments.
S1305 Contributions/donations by the Government to international institutions
S1306 Remittance towards payment / refund of taxes.
S1307 Outflows on account of migrant transfers including personal effects

17
Gr. No. Purpose Group Purpose Description
Name Code

14 Primary Income S1401 Compensation of employees

S1402 Remittance towards interest on Non-Resident deposits
(FCNR(B)/NR(E)RA, etc.)
S1403 Remittance towards interest on loans from Non-Residents (ST/MT/LT
loans) e.g. External Commercial Borrowings, Trade Credits, etc.
S1405 Remittance towards interest payment by ADs on their own account (to
VOSTRO a/c holders or the OD on NOSTRO a/c.)
S1408 Remittance of profit by FDI enterprises in India (by branches of foreign
companies including bank branches)
S1409 Remittance of dividends by FDI enterprises in India (other than
branches) on equity and investment fund shares
S1410 Payment of interest by FDI enterprises in India to their Parent company
abroad.
S1411 Remittance of interest income on account of Portfolio Investment in India
S1412 Remittance of dividends on account of Portfolio Investment in India on
equity and investment fund shares
15 Others S1501 Refunds / rebates / reduction in invoice value on account of exports
S1502 Reversal of wrong entries, refunds of amount remitted for non-exports
S1503 Payments by residents for international bidding
S1504 Notional sales when export bills negotiated/ purchased/ discounted are
dishonored/ crystallised/ cancelled and reversed from suspense account
S1505 Deemed Imports (exports between SEZ, EPZs and Domestic tariff
areas)
16 Maintenance and S1601 Payments on account of maintenance and repair services rendered for
repair services Vessels, ships, boats, warships, etc.
(not included S1602 Payments on account of maintenance and repair services rendered for
elsewhere)
aircrafts, space shuttles, rockets, military aircrafts, helicopters, etc.
17 Manufacturing S1701 Payments for processing of goods
services (goods
for processing)

18
 Self-declaration for portfolio investment under LRS

Date:

To,

The Branch Manager,

State Bank of India

Sub: General portfolio investment under the RBI’s LRS scheme, not amounting to establishing or
managing an entity abroad

Dear Sir/Madam,

I Kartik Verma
_________________________ (insert full name), hold an account with your bank under the
number: _____________________________ (insert account number). I would like to transfer USD
38915851872
1.0
$____________________ (insert amount of transfer) to Apex Clearing, USA for undertaking
portfolio investments.

Further, I hereby declare that:

● The investment is in listed securities only
● The shares proposed to be acquired are in an existing security
● I shall not have substantial or majority percentage stake in the overseas entity that I invest
in
● I shall be a passive investor and not an active investor in the non-resident entity. i.e., I will
not be managing the affairs of the company I invest in
● I have not/will not be incorporating or setting up the said overseas entity
● The funds would not be utilized for any speculative trading or for margin trading

Thanking you,

Yours truly,
Kartik Verma
(____________________)