For Official Use only Track No. SOL ID AD CODE Rate by Client Rate by ICICI Bank Deal ID Rate Application for Outward Remittance I. Details of the Applicant (Remitter) Name of the Applicant Address of the Applicant Contact Details II. Details of Outward Remittance For remittance of Foreign Currency Foreign Currency FC Amount in Figures FC Amount in Words Indian Currency equivalent to Foreign Currency Foreign Currency INR Amount in Figures INR Amount in Words III. Purpose of Remittance with Purpose Code Code Description IV. I / We authorize you to debit my / our below Account together with your charges * Charges borne by beneficiary ( BEN ) * Charges will be to the Account of Beneficiary (BEN) if no option is selected Charges borne by remitter (REM) Page 1 of 8
V. Beneficiary Details : Beneficiary Name Beneficiary Address Beneficiary A/c Number Name of the Beneficiary Bank SWIFT & SORT Code details of beneficiary Bank IBAN for remittance made to UK, Europe, Bahrain Saudi Arabia & UAE Sort Code for remittance to UK (or) BSB Code for remittance to Australia SWIFT code (or) routing Number for remittance to any other Country VI. Furnish the following details of Correspondent Bank if the Foreign Currency is sent to a Country other than the home Country of the Currency Swift Code Correspondent Bank Name Declarations: 15CA /CB : This is to certify that I/We (Name of the remitter) having PAN No. is remitting a sum of (currency) /- (Amount in words) to (Name and Address of the Payee) in respect of (Nature of expenses). I/ We hereby confirm that amount to be remitted is not chargeable to be taxed in India because (please provide rational). Therefore Form 15CA and Form 15CB as per provisions of Rule 37BB of the Income Tax Rules, 1962 are not required to be submitted. Page 2 of 8
In the event if there is any Income Tax query/inquiry/notice demanding details/information in India in respect of this particular remittance, I/We undertake to provide with all the necessary information/document to ICICI Bank as required by the Income tax department. Further, I/We shall indemnify ICICI Bank for any tax/interest or penalty levied by the Income-tax/Income tax Appellate Authorities/Courts in India for non deduction of tax or non-compliance with the relevant provisions of Income tax law in regards to this remittance. (Name of the client / Authorized signatory) (PAN of Remitter) (Account Number of the client FEMA : (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 undertake 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 Other Declarations: a. 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. b. I/we agree that in the event of transaction could not be executed/debited to my/ our account after submitting the request for processing to the bank on account of insufficient/ unclear balance at the same time of execution of the transaction in my/ our account any exchange losses incurred in this connection due to reversal of the Forex deal can be charged to my/our ICICI account. c. I/we agree that in the event the transaction is cancelled or revoked by me/us after submitting the request for processing to the bank any exchange losses incurred in this connection can be charged to my/our ICICI account. I/we further agree that once the funds remitted by me/us have been transmitted by ICICI bank to the correspondent and/or beneficiary banks, ICICI bank shall not be responsible for any delays I the disbursement of such funds including the withholding of such funds by the correspondent and/or beneficiary banks. d. I/We further agree that once the funds remitted by me / us have been transmitted by ICICI Bank, intermediary Bank charges may be levied by Correspondent and / or Beneficiary Banks, which may vary from bank to bank. e. I/we agree that in the event the transaction being rejected by the beneficiary bank because of incorrect information submitted by me, any charges levied by the beneficiary bank or exchange losses incurred in this connection can be charged to my ICICI bank account. f. 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 in contemplated by me/us, report that matter to the RBI. g. I/we also agree that the exchange rate will be applicable at the time of deal booking and may vary from the rate prevailing when the request is submitted. I/we also understand that the rate communicated to us (if any) is an indicative rate and the actual rate may be different from the same. I / We authorize you to remit outwardly as per details provided in the application. Date. Page 3 of 8 Signature of Remitter (Authorised Signatory)
I certify that I have verified the Customer s signature as per Bank records and retained the originals of all the scanned documents and forms submitted by the remitter for the above transaction Name & employee ID Bank Stamp & Employee Signature PURPOSE CODE PURPOSE CODE DESCRIPTION FOR REPORTING UNDER FETERS Capital Account S0017 S0019 S0026 S0027 S0099 Acquisition of non-produced non-financial assets (Purchase of intangible assets like patents, copyrights, trademarks etc., land acquired by government, use of natural resources) Government Acquisition of non-produced non-financial assets (Purchase of intangible assets like patents, copyrights, trademarks etc., use of natural resources) Non-Government Capital transfers ( Guarantees payments, Investment Grand given by the government/international organization, exceptionally large Non-life insurance claims) Government Capital transfers ( Guarantees payments, Investment Grand given by the Non-government, exceptionally large Non-life insurance claims) Non-Government Other capital payments not included elsewhere Foreign Direct Investment S0003 S0004 S0005 S0006 S0007 S0008 Indian Direct Investment abroad (In Branches and wholly owned Subsidiaries) Indian Direct investment abroad (in subsidiaries and associates) in debt instruments Indian investment abroad in real estate Repatriation of Foreign Direct Investment made by overseas Investors in India in equity shares Repatriation of Foreign Direct Investment in made by overseas Investors India in debt instruments Repatriation of Foreign Direct Investment made by overseas Investors in India in real estate Foreign Portfolio Investments S0001 Indian Portfolio investment abroad in equity shares S0002 Indian Portfolio investment abroad in debt instruments S0009 Repatriation of Foreign Portfolio Investment made by overseas Investors in India in equity shares S0010 Repatriation of Foreign Portfolio Investment made by overseas Investors in India in debt instruments External Commercial Borrowings S0011 S0012 S0013 S0014 S0015 S0016 S0020 S0021 Loans extended to Non-Residents Repayment of long & medium term loans with original maturity above one year received from Non-Residents Short Term Loans Repayment of short term loans with original maturity up to one year received from Non-Residents Banking Capital Repatriation of Non-Resident Deposits (FCNR(B)/NR(E)RA etc) Repayment of loans & overdrafts taken by ADs on their own account. Sale of a foreign currency against another foreign currency Financial derivatives and others Payments made on A/c of margin payments, premium payment and settlement amt etc. under Financial derivative transactions. Payments made on account of sale of share under Employee stock option S0022 S0023 Investment in Indian Depositories Receipts (IDRs) Remittances made under Liberalized Remittance Scheme (LRS) for Individuals External Assistance Page 4 of 8
S0024 S0025 External Assistance extended by India. e.g. Loans and advances extended by India to Foreign Govt. under various agreements Repayments made on account of External Assistance received by India. Imports S0101 S0102 S0103 S0104 S0108 S0109 Advance payment against imports made to countries other than Nepal and Bhutan Payment towards imports- settlement of invoice other than Nepal and Bhutan Imports by diplomatic missions other than Nepal and Bhutan Intermediary trade/transit trade, i.e., third country export passing through India Goods acquired under merchanting / Payment against import leg of merchanting trade* Payments made for Imports from Nepal and Bhutan, if any Transport S0201 S0202 S0203 S0204 S0205 S0206 S0207 S0208 S0209 S0210 S0211 S0212 S0214 S0215 S0216 S0217 S0218 S0219 S0220 S0221 S0222 S0223 S0224 Payments for surplus freight/passenger fare by foreign shipping companies operating in India Payment for operating expenses of Indian shipping companies operating abroad Freight on imports Shipping companies Freight on exports Shipping companies Operational leasing/rental of Vessels (with crew) Shipping companies Booking of passages abroad Shipping companies Payments for surplus freight/passenger fare by foreign Airlines companies operating in India Operating expenses of Indian Airlines companies operating abroad Freight on imports Airlines companies Freight on exports Airlines companies Operational leasing / Rental of Vessels (with crew) Airline companies Booking of passages abroad Airlines companies Payments on account of stevedoring, demurrage, port handling charges etc.(shipping companies) Payments on account of stevedoring, demurrage, port handling charges, etc.(airlines companies) Payments for Passenger - Shipping companies Other payments by Shipping companies Payments for Passenger - Airlines companies Other Payments by Airlines companies Payments on A/c of freight under other modes of transport (Internal Waterways, Roadways, Railways, Pipeline transports and others) Payments on account of passenger fare under other modes of transport (Internal Waterways, Roadways, Railways, Pipeline transports and others) Postal & Courier services by Air Postal & Courier services by Sea Postal & Courier services by others Travel S0301 S0303 S0304 S0305 S0306 Business travel. Travel for pilgrimage Travel for medical treatment Travel for education (including fees, hostel expenses etc.) Other travel (including holiday trips and payments for settling international credit cards transactions) Construction Services S0501 S0502 Construction of projects abroad by Indian companies including import of goods at project site abroad Cost of construction etc. of projects executed by foreign companies in India. Insurance and Pension Services S0601 Life Insurance premium except term insurance Page 5 of 8
S0602 S0603 S0605 S0607 S0608 S0609 S0610 S0611 S0612 Freight insurance relating to import & export of goods Other general insurance premium including reinsurance premium; and term life insurance premium Auxiliary services including commission on insurance Insurance claim Settlement of non-life insurance; and life insurance (only term insurance) Life Insurance Claim Settlements Standardized guarantee services Premium for pension funds Periodic pension entitlements e.g. monthly quarterly or yearly payments of pension amounts by Indian Pension Fund Companies. Invoking of standardized guarantees Financial Services S0701 S0702 S0703 Financial intermediation, except investment banking - Bank charges, collection charges, LC charges etc. Investment banking brokerage, under writing commission etc. Auxiliary services charges on operation & regulatory fees, custodial services, depository services etc. Telecommunication, Computer & Information Services S0801 S0802 S0803 S0804 S0805 S0806 S0807 S0808 S0809 S0901 S0902 Hardware consultancy/implementation Software consultancy / implementation Data base, data processing charges Repair and maintenance of computer and software News agency services Other information services- Subscription to newspapers, periodicals Off-site software imports Telecommunication services including electronic mail services and voice mail services Satellite services including space shuttle and rockets etc. Charges for the use of intellectual property.i.e Franchises services Payment for use, through licensing arrangements, of produced originals or prototypes (such as manuscripts and films), patents, copyrights, trademarks and industrial processes etc. Other Business Services S1002 S1003 S1004 S1005 S1006 S1007 S1008 S1009 S1010 S1011 S1013 S1014 S1015 S1016 S1017 S1018 S1020 S1021 Trade related services commission on exports / imports Operational leasing services (other than financial leasing) without operating crew, including charter hire- Airlines companies Legal services Accounting, auditing, book-keeping services Business and management consultancy and public relations services Advertising, trade fair service Research & Development services Architectural services Agricultural services like protection against insects & disease, increasing of harvest yields, forestry services. Payments for maintenance of offices abroad Environmental Services Engineering Services Tax consulting services Market research and public opinion polling service Publishing and printing services Mining services like on site processing services analysis of ores etc. Commission agent services Wholesale and retailing trade services. Page 6 of 8
S1022 S1023 S1099 Operational leasing services (other than financial leasing) without operating crew, including charter hire- Shipping companies Other Technical Services including scientific/space services. Other services not included elsewhere Personal, Cultural & Recreational Services S1101 S1103 S1104 S1105 S1106 Audio-visual and related services like Motion picture and video tape production, distribution and projection services. Radio and television production, distribution and transmission services Entertainment services Museums, library and archival services Recreation and sporting activities services S1107 Education (e.g. fees for correspondence courses abroad ) S1108 S1109 Health Service (payment towards services received from hospitals, doctors, nurses, paramedical and similar services etc. rendered remotely or on-site) Other Personal, Cultural & Recreational services Government not included elsewhere S1201 Maintenance of Indian embassies abroad S1202 Remittances by foreign embassies in India Secondary Income S1301 S1302 S1303 S1304 S1305 S1306 S1307 Remittance for family maintenance and savings Remittance towards personal gifts and donations Remittance towards donations to religious and charitable institutions abroad Remittance towards grants and donations to other governments and charitable institutions established by the governments. Contributions/donations by the Government to international institutions Remittance towards payment / refund of taxes. Outflows on account of migrant transfers including personal effects Primary Income S1401 S1402 S1403 S1405 S1408 S1409 S1410 S1411 S1412 Compensation of employees Remittance towards interest on Non-Resident deposits (FCNR(B)/NR(E)RA, etc.) Remittance towards interest on loans from Non-Residents (ST/MT/LT loans) eg. External Comm. Borrowings, Trade Credits, etc. Remittance towards interest payment by ADs on their own account (to VOSTRO a/c holders or the OD on NOSTRO a/c) Remittance of profit by FDI enterprises in India (by branches of foreign companies including bank branches) Remittance of dividends by FDI enterprises in India (other than branches) on equity and investment fund shares Payment of interest by FDI enterprises in India to their Parent company abroad. Remittance of interest income on account of Portfolio Investment in India Remittance of dividends on account of Portfolio Investment in India on equity and investment fund shares Others S1501 S1502 S1503 S1504 S1505 Refunds / rebates / reduction in invoice value on account of exports Reversal of wrong entries, refunds of amount remitted for non-exports Payments by residents for international bidding Notional sales when export bills negotiated/ purchased/ discounted are dishonored/ crystallized/ cancelled and reversed from suspense account Deemed Imports (exports between SEZ, EPZs and Domestic tariff areas) Page 7 of 8
Maintenance and repair services.i.e S1601 S1602 Payments on account of maintenance and repair services rendered for Vessels, ships, boats, warships, etc. Payments on account of maintenance and repair services rendered for aircrafts, space shuttles, rockets, military aircrafts, helicopters, etc. Manufacturing services (Goods and Processing) S1701 Payments for processing of goods Page 8 of 8