Amount Remitted

_US Dollars_____$____________ Currency Amount Equivalent to Rupees ___________________

FORM A1 (For Import Payment Only)

(Application for Remittance in Foreign Currency)

(To be completed by Authorized Dealer)

Importer Code No. _____________________ Serial No. _____________________ (for use of Reserve Bank of India) A.D. Code No. 06910204-6000009 Form No. ___________________________ (To be filled by Authorised Dealer)

I/ We wish to purchase ______________________________________________________________________________________________________ (Name of currency) (Amount in words) through _______________________________________________________________________________________________________ (Name and address of the Authorised Dealer) _________________________________________________________________________ _in payment of (Name and address of the Beneficiary of the remittance) ___________________________________________________________________________________________________________________ imports into India, detailed below: Details of goods imported or to be imported into India Section A: Import Licence/Open General Licence Particulars O.G.L. NUMBER PART SCHEDULE SERIAL NUMBER Import Licence Date of issue Date of expiry Face value Amount to be Balance outendorsed Standing on the Prefixes Licence No. Suffixes Date Month Year Date Month Year of licence (in rs. ) @ Licence after the remittance 1 2 1 2 3 4 5

@ Actual Amount endorsed in Rupees against each licence involved should be stated under this column. NOTE: If more than one licence is involved, particulars of all licences should be furnished in inadequate, a separate statement may be attached. The amount utilised against each licence should invariably be indicated. Invoice Details Qty of goods Section B: Import particulars Description of goods Harmonised Country of Country from System of origin of goods which goods Classificati are consigned on Mode of Date of Shipment Shipment (if (air, sea, not known post, rail, approximate river, date) transport etc.

Invoice No. and Date

Terms Currency Amount (c.i.f.) F.O.B. c.& f. etc.

Section C: Other particulars _____________________ (No. & Date of Contract) of contract) 2. If remittance to be made is less than invoice value reason therefore (i.e. part remittance, instalment etc.) 1. Details of forward purchase contract if any, booked against the import.

_________________ ______________ (Currency and Amount (Balance under the contract) ____________________________________ ____________________________________

I/We hereby declare that the statement made by me/us on this form are true and that I/We have not applied for an authorization through any other bank. I/We declare and also understand that the foreign exchange to be acquired by me/us persuant to this application shall be used by me/us only for the purpose for which it is acquired and that the conditions subject to which the exchange is granted will be complied with. Name of Applicant(s) : Nationality of Applicant(s) (Bank Capitals) ____________________________ (Bank Capitals) _____________________________________________ Address of Applicant(s) : (Bank Capitals) ____________________________ ________________________________________________________________ Date: ___________ Note: for remittances covering intermediary trade. Form A2 should be used. Signature of Applicant

Declaration to be furnished by Applicant I/we declare that (a) (b) (c) (d) the import licence/s against which the remittance is sought is/ are valid and has/ have been cancelled by DGFT authorities. the goods to which this application relates as have been/ will be imported into India on my/our account.* The import is on behalf of ___________________________________________________________________________________" and the invoice value of the goods which is declared on this form is the real value of the goods imported"/ to be corp[orated into India. I/we attach the relative Customs stamped Exchange Control copy of Bill of Entry" Post parcel wrapper (for imports by post/courier wrapper (for imports through courier)" Or I/we undertake to produce within three months to be authorized dealer the relative Custom-stamped Exchange control copy of Bill of Entry" Post parcel wrapper (for imports by post/courier wrapper (for imports through courier)"

If the import has been made. If the import is to be made.

* Strike out whichever applicable. @ where the import is no behalf of Central/State Government Department or a company owned by Central/State/Government Statory Corporation, Local body etc. The name of the Government Depatmen, Corporation etc. Should be stated. Date : __________ ________________________________________ (Signature of Applicant/ Authorised Official)

(Space for comments of the Authorisd Dealer) (While forwarding the application to the Reserve Bank of India for approval Reference to Exchange Control Manual paragraph, A.D. circular, in terms of which the reference is made should invariably be cited. If any remittance application on account of the same import was required to the Reserve Bank earlier, reference to the last correspondence/approval should also be cited.) (Stamp and Signature of Authorised Dealer)

Stamp

Name:____________________________________________ Designation _______________________________________ Name & Address of _________________________________ Authorized Dealer___________________________________

Date: ______________ Certificate to be furnished by Authorized Dealer (Importers Banker) We hereby certify that, (a) this payment is Put a (i) tick () (ii) in the relevant (iii) an advance remittance. in retirement of bills under Letter of Credit opened through us. against documents received through our medium for collection. on account documents received by the applicant(s) against undertaking furnished by the letter to submit Customs-stamped Exchange Control Copy of Bill of Entry/Post Parcel Wrapper within three months on account of documents received direct by the applicant(s) against Custom-Stamped Exchange Control Copy of Bill of Entry/Post Parcel Wrapper (attached submitted by the letter)

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(iv) (v) (vi) (any other case to be explained) all the Exchange Control Regulations applicable to the remittance have been complied with the payment to the suppliers of the goods has been* made through ______________________________________ will be (Name and address of the foreign Bank) We also certify/undertake that the relevant Customs-stamped Exchange Control Copy of Bill of Entry or Post Parcel Wrapper * shall be verified by us within three months (vide certificate (a) (ii) and (iii) above) * has been verified (vide certificate (a) (v) above) * shall be obtained from the applicant(s) within three months (vide certificate (a) (i) and (iv) above) Stamp and Signature of Authorised Dealer) (b) (c)

Stamp

Name:____________________________________________ Designation _______________________________________ Name & Address of _________________________________ Authorized Dealer___________________________________

Date: ____________________________ * Strike out item not applicable

To THE BRANCH MANAGER UNION BANK OF INDIA BQ BLOCK SHALIMAR BAGH NEW DELHI 110088

FORM 2

DECLARATION-cum-UNDERTAKING [Under Section10 (5), Chapter III of The Foreign Exchange Management Act, 1999] I/We hereby declare that the transaction the details of which are specifically mentioned in the Schedule hereunder 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 thereunder. 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. 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 undertake 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 further declare that the undersigned has/have the authority to give this declaration and undertaking on behalf of the firm/company. Signature of the Applicant for Foreign Exchange Place Date: Name : Address: IEC Code No.:

* Applicable when the declaration/undertaking is signed on behalf of the firm/company. Schedule 1. Nature/Purpose of Foreign Exchange transation : ______________________________________ : ______________________________________ : ______________________________________ : ______________________________________ : ______________________________________ : ______________________________________

2. 3.

Amount of Foreign Exchange Beneficiary

For Office Use: Details of documentary evidence verified