F O R M A-1(for import payment only)

AD Code No: ____________________________Serial No:

Ref No : ( for use of Reserve Bank of India )Amount : Form No:( To be completed by authorised dealer ) ( To be filled by authorised dealer )

only through __________BANK for payment toDetails of the import are as under:

Section A : Import Licence / Open General Licence ParticularOGL… CHAPTER / V PARA 5.1 OF EXPORT IMPORT POLICY 2002 - 2012

Number Part Schedule Serial Number

Import Licence Date of Issue Date of Expiry

PreffixesLicence No

SuffixesDa

te

Mon

th

Year

Date

Mon

th

Year

1 2 1 2 3 4 5

@ Actual amount endorsed in rupees against each licence involved should be stated under this column.Note: If more than one licence is involved, particulars of all licences should be furnished. If the space is inadequate,a separate statement may be attached. The amount utilised against each licence should invariably be indicated.

Section B : Import ParticularsInvoices Details

No. & Date

Curr

ency

Amount

BTN

Cla

ssifi

catio

n

Section C : Other Particulars

No. & date of contract currency & amt. of contract balance under the contractRupees Forty Three Thousand Seven Hundred One and Ninety Six PaiseNo Rupees Only

Name of Applicants :Nationality of Applicant (s): For

Address of Applicant :

Application for Remittance in Foreign Currency

We wish to purchase (amount in words)

Face Value of Licence

Amt. Endorsed

in Rs.

Balance o/s on the licence after the remittance

Term

s (CI

F, F

OB,

C&

F et

c) Qty. of Goods

Description of Goods

Coun

try

of O

rigin

of

Good

s

Coun

try

form

whi

ch

good

s are

con

signe

d

Mod

e of

Shi

pmen

t (a

ir/se

a/po

st/ r

ail/

river

/tra

nspo

rt e

tc.)

Date

of s

hipm

ent (

if no

t kno

wn

appr

oxim

ade

date

)1. Details of forward purchase contracts, If any, booked against the import.

2. If remittance to be made is less than invoice value, reasons therefore (i.e., part remittance 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 / We declare and also understand that the foreign exchange to be acquired by me / us pursuant to this application shall be used by me / us only for the purpose for which it is acquired and that the conditions subject to which the exchange is granted will be complied with.

Date :Authorised Signatory

Declaration to be furnished by Applicants (s)I / We declare thata) the goods to which the application relates have been/will be* imported into India on my/our account* b) the import is on behalf of @ andc) the invoice of the goods which is declared on this form is the value of the goods imported / to be imported* into india If the import has been made: I/We attach the relative custom stamped Exchange Control Copy of Bill of Entry /

post Parcel wrapper (for import by post)If the import has to be made: I/We undertake to produce within three months to be authorised dealer the relative

Custom-stamped exchange control copy of Bill of Entry*/Post Parcel Wrapper (for imports by post)*Strike out item not applicable.@ (where the imports is on behalf of central / State Government Department or a company owned by Central / State Govt /statutory Corporation, Local Body, etc. the name of the government department, corporation etc. should be stated)

Date : For

Authorised Signatory

Space for comments of the authorised dealers while forwarding the application to the Reserve Bank of India for approval (Reference to Exchange Control Manual paragraph AD circular in terms of which the reference is made should invariably be cited.)

For

Date :Stamp Signature of Authorised Officials

Certificate to be furnished by Authorised Dealers (Importer Banker)

We here by certify that(Put a tick P in the relevant block)

(i) An advance remittance.(ii) In retirement of bills under Letter of Credit opened through us.(iii) Against documents received through our medium for collection.(iv) On account of documents received direct by the applicant(s) against undertaking furnished by the latter to submit

customs-stamped exchange control copy of bill of entry /post parcel wrapper within three months. (v) On account of documents received direct by the applicant(s) against customs-stamped exchange control copy of

Bill of Entry/post parcel wrapper (attached) submitted by this latter.(vi) …………………………………………………………..(any other case, to be explained)

(Name and address of the foreign bank)We also certify/undertake that the relevant customs-stamped exchange control copy of bill of entry of post parcel wrapper.(* strike out item not applicable)

shall be verified by us within three months (vide certified a II and III above)has been verified (vide certificate a (v) above)shall be obtained from the applicant(s) and forwarded to the reserve bank within three months(vide certificate a (i) and (iv) above)

For

a) this payment is

b) all the exchange control regulations applicable to the remittance have been complied withc) the payment to the supplier of the goods has been / will be* made through-----------------------------------------

Date:

(Stamp & signature of Authorised officials)