(For payments other than imports and AD Code No………………….

remittance covering intermediary trade) Form No…………………………

(To be filled by the Authorised dealer)


Application for Remittance Abroad Serial No…………………….

(For use of Reserve Bank of India)

Currency ……………………

Amount …………………….

Equivalent to Rs……………

(To be completed by authorised dealer)

I/ We wish to purchase____________________________________________ (Name of currency and amount in words) through __________________________________(Name and address of the Authorised dealer) for payment to _______________________________(Name and address of the beneficiary) be remitting the amount/by credit to the account of _____________________(Full title of the account & country of non-resident bank and name of AD with whom account is maintained) for the purpose indicated bellow :

) against an appropriate purpose code. In case of doubt/difficulty, consult your bankder.)3(Remitter should put a tick (

Code Purpose Code Purpose

Capital Account Transactions Insurance

S001 Investment in shares abroad by residents S501 Life Insurance premium

S002 Investment in Debt Securities abroad by residents S502 General Insurance premium

S003 Investment in branches/subsidaries abroad by residents S503 Reinsurance premium

S004 Investment in real estate abroad by residents S504 Insurance Commission

S005 Repatriation of foreign investment in shares S510 Other Insurance payments

S006 Repatriation of foreign Investment in Debt Securities Other Services

S007 Repatriation of foreign investment in subsidiaries/branches S601 Postal/Telecom Services

S008 Repatriation of foreign investment in real estate S602 Project abroad

S009 Loans to non-residents S603 Bank charges/commission

S010 Repayment to LT/MT loans S604 Soft/Hardware consultancy, services

S011 Repatriation of NR deposits S605 Subscription of periodicals, Correspondence courses

S012 Repayment of ST (6m. to 1 Yr.) Loans S606 Computer and IT services

S013 Repayment of loans/ODs by banks S607 Royalty, License fees

S013 Repayment of loans/ODs by banks S608 Professional service, Technical fees

S014 National sale for credit to NRI deposits S609 Refunds and rebates on trade

S015 Other capital account payments S610 Other remittances

Other import pay Form A1 Payments not covered by Government, Not included elsewhere

S103 Imports by diplomatic mission S701 Maintenance of Indian Embassies

S104 Imports under intermediary trade S702 Remittance by Foreign Embassies

Travel Transfers

S301 Business travel S801 Foreigner’s family maintenance

S302 Travel for Medical purpose S 802 Private gift/donation

S303 Travel for education S 803 Grants donations of charity by Govt.

S305 Travel for pilgrimage S 804 Contribution by Govt. to international institutions

S310 Other travel payments (including credit card) S 810 Other transfers

Transportation Income

S401 Shipping transport-Remittance by fgn. cos. S901 Interest on NRI deposits

S402 Air trasnport-Remittance by fgn. cos. S 902 Interest on loans

S403 Shipping trasnport-Remittance by Indian cos. S903 Dividends, profits

S404 Air transport- Remittance by Indian cos. S904 Interest on debentures /bonds

S405 Freight on imports S905 Interest on Ods in Nastro A-cs.

S406 Freight on exports S 906 Salary of Non-residents

S407 Charter hire charges (Airline cos.) S 910 Other income

S408 Charter hire charges (Shipping cos.)

S409 Booking of passage in foreign countries

S410 Other transportation (e.g. demurrage etc.)


I/We hereby declare that the statements made by me/us on this form are true and that I/we have not applied for an authorisation through any other bank.

I/Se declare and under stand that the foreign exchange to be acquired/payment to be made by me/us pursuant to this application shall be used/made be me/us only for the purpose for which it is acquired/to be made and that the conditions subject to which the exchange/permission is granted will be complied with.

I/We desire to travel to————————-via—————————–for the purpose of——————-Passage has been booked through——————————————————————–

(Name of airline/shipping co. or passage agent)

—————————————–The date of departure is——————————-The exchange is required in the form of

Currency Amount

Notes & Coins ————– ————–

Tr. Cheques ————— ————–

Drafts ————– —————

Letter or Credit ————– —————

Total ————- —————

Name of Applicant(s)————————————-Nationality of Applicant(s)———————-

Address of applicant(s)—————————————————————————-

Date—————————– Signature of Applicant(s)/ Authorised Official

(Space for comments of the Authorised Dealers)

While forwarding the application to Reserve Bank of India for approval, reference to EXM paragraph/AD circular in terms of which the reference is made should invariably be cited.)

Approval for similar remittances was obtained from the Reserve Bank of India vide Permit



(Stamp and Signature of Authorised Official)

Name & Designation ____________________

Name & Address of Authorised Dealer________

Certificate to be furnished by Authorised Dealers

(Applicant’s Banker)

We hereby certify that

A. the remittance has been made

It terms of authority delegated to authorised dealers vide paragraph ——————————–of the Exchange Control Manual and/or A.D. Circular No.————–dated——————-


In terms of Reserve Bank Permit No. ———————dated——————–

B. all the Exchange Control Regulations applicable to the remittance have been complied with.

C. documentary evidence in support of the payment has been verified.

D. payment to the beneficiary has been/will be made through———————-

(Name and address of the designated bank in ACU member country)


(Stamp and Signature of Authorised Official)

Name & Designation______________________

Name & Address of

Authorised Dealer _______________________


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