Complete

A2 Form/Declaration
FORM A2 T O BE COMPLET ED BY LOCAL BANK AD DEALER
(For payments other AD Code No.
than imports and
Form No.
remittances covering
intermediary trade)
Currency INR Amount 578,4 94 .00
Equivalent to Rs 578,4 94 .00
(Amount is rounded off to the nearest rupee)
RTGS / NEFT Ref No

Application for Remittance Abroad

I/We Premnath
Jayaprakash
(Name of applicant remitter)
PAN No.
Address: 507, K.v.k. samy street periya nagar, Chennai
Tamilnadu, INDIA, 600039
Authorize:
(Name of AD branch)
To debit my Savings Bank/Current/RFC/EEFC A/c No undefined
together with their charges and Effect the foreign exchange remittance directly.
1) Beneficiary's Name Premnath
Jayaprakash

Beneficiary's Address 507, K.v.k. samy street periya nagar, Chennai

Tamilnadu, INDIA, 600039

Beneficiary's Account No CIBC062925647886

2) Beneficiary Bank name: Canadian Imperial Bank of Commerce

Beneficiary Bank address: 595 Bay Street, 7th Floor, Toronto, ON M5G
2M8, Canada
3) Beneficiary Bank Account No: CIBC062925647886
Beneficiary Bank SWIFT BIC CC001033613
CIBCCATT
Intermediary Bank IFSC Code SCBL0036001
Whether under LRS
Sr. No. Purpose Code Description
(Yes/No)
Travel for education (including
fees, hostel expenses etc)
Fld 70: ISBO

1 YES S0305 GIC-20010184

Premnath
Jayaprakash
20008572
1
As per the Annex


Declaration
(Under FEMA 1999)

1. I, Premnath
Jayaprakash , 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. Name and address of AD branch/FFMC through which
Date Amount
No the transaction has been effected
1

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 250,000 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.

Premnat h Jayaprakash
Signat ure of t he applicant
Dat e: January 5, 2020, 11:02 PM