(To be printed on White paper) FORM A 4 (To be completed for debits and credits to non-resident accou s 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 .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)
