ANNEXURE -A

FORMAT -I
(Application cum declaration for the purchase of foreign exchange under Liberalized Remittance Scheme of USD 250000- To be
obtained on client’s letterhead for release of forex under Business Visit.)

Date 26/09/2019

To,
The Manager,
M/s. R. R. Sen & Bros (P) Ltd,
………………………………….
…………………………………..
Dear Sir,

Sub: RELEASE OF FOREIGN EXCHANGE FOR BUSINESS VISIT

We wish to draw Foreign Exchange for Business Visit against our sponsorship as per the details given below:
NAME (S) : SUNIL KUMAR
NATIONALITY : INDIAN
PASSPORT NO. DATE &
PLACE OF ISSUE : J6696060, 11/04/2011, DELHI
DESIGNATION/S : SR. MANAGER
RESIDENTIAL ADDRESS/ES : H.NO: 4, GALI NO: 4, SHAHID BHAGAT SINGH COLONY, KARAWAL NAGAR
DELHI -94

COUNTRY TO VISIT : USA

PURPOSE OF VISIT : Business
EXCHANGE REQUIRED : 2180

We undertake to bear the total expenses for the trip and utilize the foreign exchange for the above stated purpose only. We confirm
that the foreign exchange applied for and quantum of currency notes to be purchased is within the permissible limit. Our PAN
Is__________________________.
The sources of funds is_____________________________________________________.

Details of the remittances made/transactions effected under the scheme in the current financial year (April-------------
March--------)

Sr. No. Date Amount Name & Address of AD branch/FFMC through which the transaction has been
effected

DECLARATION
We ………………………………………………………………..(Name), hereby declare that the total amount of foreign exchange
purchased from or remitted through, all sources in India during the financial year as stated above in the application is within the
overall limit of USD 2,50,000 (US Dollar Two Hundred and Fifty Thousand Only), which is the limit prescribed by the Reserve Bank
of India for the purpose and certify that the source of funds for making the said remittance belongs to us and the foreign exchange
will not be used for any prohibited purposes.
We are forwarding herewith cheque No………………drawn on…………..…………for Rs:…………………towards the concerned
payment and the following provisional Data for your ready reference.

Airlines……………………………………….. Ticket No. …………………………. Journey date…………………

Thanking you,

Authorized Signatory
With seal and Designation
 ANNEXURE -A

DECLARATION-cum-UNDERTAKING
[Under Section 10(5), Chapter III of the Foreign Exchange Management Act, 1999]

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.
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.
We also understand that if 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 us report the matter to the Reserve Bank of India.

*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:-

*Applicable when the declaration/undertaking is signed on behalf of the firm/company

Certificate by the Authorized 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 Authorized Official:-

(Stamp and Seal)

Signature:-

Date:-

Place:-

SCHEDULE

Nature/Purpose of Foreign Exchange transaction___________________________________________________________

Amount of Foreign Exchange___________________________________________________________________________

Beneificiary__________________________________________________________________________________________________

For Office Use: - Details of documentary evidence verified

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