(To be printed on White paper)

FORM A 4
(To be completed for debits and credits to non-resident accounts of all types
other than the accounts of non-resident banks, requiring approval of
Reserve Bank or for report to Reserve Bank)

For debit* From the account of_________________________________________________
(Name and address of non-resident account holder
stating country of residence and type of account)
at _______________________________________________________________
(Name of authorised dealer or authorised co-operative/
commercial bank with whom account is kept)
for payment to_____________________________________________________
(Name and address of the resident beneficiary)
Amount Rs.________________ _____________________________________
(in figures) (in words)
The purpose of payment is ___________________________________________
_________________________________________________________________
For credit* From ____________________________________________________________
(Name and address of the resident/non-resident remitter)
for credit to the account of ___________________________________________
(Name and address of non-resident
_________________________________________________________________
account holder stating country of residence and type of account)
at _______________________________________________________________
(Name of authorised dealer or authorised co-operative/commercial
bank with whom account is kept)
Amount Rs._________________ ____________________________________
(in figures) (in words)
The purpose of payment is ___________________________________________
_________________________________________________________________
For transfer* From the account of
_________________________________________________
(Name and address of non-resident account holder
stating country of residence and type of account)
at
________________________________________________________________
(Name of authorised dealer or authorised co-operative/
commercial bank with whom account is kept)
for transfer to the account of __________________________________________
(Name and adddress of non-resident
_________________________________________________________________
_
account holder stating country of residence and type of account)
at
________________________________________________________________
(Name of authorised dealer or authorised co-operative/
_________________________________________________________________
_
commercial bank with whom account is kept)
Amount Rs._________________ _____________________________________
(in figures) (in words)
The purpose of transfer is
_____________________________________________
_________________________________________________________________
_
* Relevant part should be completed.
We certify that the above payment/transfer has been made in terms of the authority
delegated to authorised dealers or authorised co-operative/ commercial banks vide paragraph
_________ of the Exchange Control Manual / Memorandum ABM and/or A.D. Circular No.
_____________.
.............................................................................
(Signature of Authorised Official)
Name : ................................................................
Designation : .......................................................
Stamp
Name and Address...............................................
Date : ................... of Authorised Dealer or ......................................
Authorised Co-operative/.....................................
Commercial Bank ................................................
(Space for comments of the authorised dealer or
authorised co-operative/ commercial bank)
While forwarding the application to Reserve Bank for approval reference to paragraph of
Exchange Control Manual or Memorandum ABM or A.D. Circular in terms of which the
reference is made should invariably be cited.
Similar transaction was approved by Reserve Bank vide approval No.___________ dated
_______________
.............................................................................
(Signature of Authorised Official)
Name : ................................................................
Designation : .......................................................
Stamp
Name and Address...............................................
Date : ................... of Authorised Dealer or ......................................
Authorised Co-operative/.....................................
Commercial Bank ................................................
(Space for use by Reserve Bank of India)