How to complete your payment

We will only accept one payment per payment reference. To make multiple payments, please repeat the process to
create a new payment reference number.

Payment reference Currency Amount to be paid

EGB38741-UK3626187 INR 2,145,150.00

This quote can only be used for one (1) payment and is valid until 17/06/2021 20:03:05 BST

1 Complete the attached ICICI form

You must print and complete the attached form. It is important the form is completed to ensure efficient
processing of your payment. Here are some tips to help you:
• Section I: the payer must provide their name, address and phone number.
• Section II (b): ensure the INR amount listed is correct and fill in the same amount in words.
• Section III: only complete this section if you will make your payment from an ICICI bank account.
• Section IV (a-g): this section does not need to be completed.
• Section V: fill in the Education section only providing the Student Name, Student ID and Country of Study.
• Signature of Remitter: sign and date the form at the end of the declaration on page 6.

2 a. Setup your payment

If you are paying from your ICICI bank account, Non-ICICI account holders must transfer funds to
you must complete Section III of the below A2 form. the ICICI Bank pooled account via NEFT or RTGS
ICICI will debit your nominated account following before visiting a branch:
your visit to your local ICICI bank branch. Beneficiary: Outward Remittance Pool Account
Please note: TCS may be levied by ICICI over and above the payment Account Number: 0035SLORCBPC
instruction amount as per regulation and you will be required to pay IFSC Code: ICIC0000035
this. The TCS will be applied during your visit at the bank branch.

b. Visit the nearest ICICI Bank location to complete the transaction

Select the Forex enabled branch from services section dropdown. You must bring the following with you to
your local ICICI branch:
• A completed Retail Outward Remittance Application – A2 cum LRS Declaration
• Proof of identity and address, either a Passport, Drivers License, Voter ID, Aadhaar Number, Letter from the
National Population Register OR Job Card issued by NREGA and signed by the State Government Office
• Your PAN card
• A copy of your Sanction letter (if your fees are being funded by a bank loan).

3 Track your payment as it is delivered to:

With the help of Western Union Business Solutions,
ICICI will deliver your payment to your institution.
Funds will arrive at your institution in 2-3 business
days. Track your payment using the link below.

student.globalpay.wu.com/tracking >

Ask us.
gpstudents@westernunion.com
Please include payment reference number and proof of
payment number for prompt response and resolution.

2017 Western Union Holdings, Inc. All rights reserved.

Western Union Business Solutions is a business unit of The Western Union Company. Services in the UK are provided by Custom House Financial (UK) Limited (which does business under the trade name of Western Union Business Solutions) or
Western Union Business Solutions (UK) Limited.
Custom House Financial (UK) Limited (registered in England, Company Number 04380026, Registered Office Address: 12 Appold Street, London EC2A 2AW) is authorised by the Financial Conduct Authority under the Payment Services
Regulations 2009 (Register Reference: 517165) for the provision of payment services and is registered as an MSB with HM Revenue & Customs (Registered No: 12140130).
Western Union Business Solutions (UK) Limited (registered in England, Company Number 02854737, Registered Office Address: 12 Appold Street, London, EC2A 2AW) is authorised by the Financial Conduct Authority under the Payment Services
Regulations 2009 (Register Reference: 536611) for the provision of payment services and is registered as an MSB with HM Revenue & Customs (Registered No: 12122416).
 Retail Outward Remittance Application - A2 Cum LRS Declaration

Track Number Originating Br. ID Scan Br. ID AD Code

For Office Use Only

Additional Information
(if any)

(To be completed by the applicant in block letters using black ink pen)
Application for drawal of Foreign Exchange
I. Details of the Applicant (Remitter)

a. Name of the Applicant

b. Address (Not mandatory

for ICICI A/c holders)

c. Applicant Phone No. d. PAN No.*

(* PAN no. is mandatory for all resident customers)
II. Details of Foreign Exchange required (Fill-up either II a or II b) (Ref Annex-III for applicable Currency Details)
II a. For remittance of fixed amount of Foreign Currency
Foreign Currency GBP FC
Amount
FC Amt in figures In Words
(OR) II b. For remittance in Foreign Currency equivalent to Fixed Rupee Amount
Foreign Currency INR
Amount
INR Amt in figures 2,145,150.00 In Words

II c. Please enter the CCIL Deal Reference Number, in case deal already booked with CCIL platform (In case no deal booked
with CCIL, please write NA) _________________________________________________________________________________________

II d. Purpose of Remittance with Remittance Scheme and Purpose Code

(Please tick (√) against the purpose code in Annexure – I)
Whether under LRS (Yes/No) Purpose Code Purpose Description

II e. Name of the country providing ultimate services:

(in case payment is for import of services for below Purpose Groups)____________________________________________________
02 (Transport) 09 (Charges for the use of intellectual property)
03 (Travel) 10 (Other Business Services)
05 (Construction Services) 11 (Personal, Cultural & Recreational services)
06 (Insurance and Pension Services) 15 (Others)
07 (financial Services) 16 (Maintenance and repair services)
08 (Telecommunication, Computer & Information Services) 17 (Manufacturing services (goods for processing))
III. I / W
e authorize you to debit my / our below Account together with your charges* III a. Please issue
Telegraphic Transfer Demand Draft
OR
TT DD
*For ICICI Bank charges please refer our website www.icicibank.com
IV. Beneficiary Name
W E S T E R N U N I O N B U S I N E S S

S O L U T I O N S
 Retail Outward Remittance Application - A2 Cum LRS Declaration

IV a. Beneficiary Address
2 0 0 H A M M E R S M I T H R O A D
L O N D O N W 6 7 D L U K

IV b. Beneficiary A/c Number (Incase of TT)

IV c. Name of the Bank where the beneficiary A/c is maintained (In case of TT)

IV d. SWIFT & SORT Code details of beneficiary Bank (In case of TT)
IBAN for remittance made Transit Code for remittance
to UK, Europe, Bahrain made to Canada
Saudi Arabia & UAE
Sort Code for remittance to
SWIFT code (or) routing
UK (or) BSB Code for
Number of beneficiary bank
remittance to Australia

IV e. Beneficiary National ID/Commercial registration/Certificate Number (mandatory if beneficiary country is Saudi Arabia)

IV f. Beneficiary Bank address including Country at which the beneficiary maintains A/c (mandatory in case of TT in CAD,
QAR & JPY Currencies)

IV g. Furnish the following details of CORRESPONDENT BANK if the Foreign Currency is sent to a Country other than the
home Country of the Currency (Eg. Remitting GBP currency to a beneficiary residing in Australia)
SWIFT CODE CORRESPONDENT BANK NAME

V a. If the purpose selected is one of the below then it is mandatory to furnish the details sought for
Maintenance Relationship of beneficiary
(Ref Table below)
Purchase of Immovable The location of property being Country____________________________________
Property purchased (Country / State) State_______________________________________

Education Student Name and Student ID

(if any). Country of study abroad
Gift Residential status of beneficiary
(Resident/NRI/Foreign National)
Emigration I/We hereby confirm that remittance request is to meet the incidental expenses in the country of
(Please check to agree) emigration and not for undertaking any capital account transactions such as overseas investment
in government bonds; land; commercial enterprise; etc.
Investment abroad 1. Equity Shares* *In Case of Shares Please Specify
(Select the nature of Name of Company
2. Mutual Funds
investment)
3. Venture Capital Fund Listed / Unlisted (Please indicate)

4. Debt Security* Stock Exchange Where Listed

5. Promissory Notes Country of Incorporation

6. Others (Specify) Type of Company (eg LLP, Ltd)

 Retail Outward Remittance Application - A2 Cum LRS Declaration
Number of equity shares to be acquired

Percentage of equity shares being acquired (Less Than

5% in overseas entity OR Equal to or greater than 5% in
the overseas entity.

Will investment be subscribed to the Memorandum of

Assocoation of the overseas entity (Yes/No)

Whether any other financial commitments such as

investment in Optionally Convertible Preference Shares,
Loan, Guarantee, etc in the overseas entity will be
undertaken (Yes/ NO)

Investment is made in existing entity and already

incorporated by others (Yes/NO):

Remitter Beneficiary relationship (Investor/Other, Please

specify)

*In Case of Debt Security Please Specify

Name of the issuing company

Investment Type

Name of the Instrument

Listed / Unlisted (Please indicate)

Stock Exchange Where Listed

List of close relatives (‘relative’ as defined in Section 2(77) of the Companies Act, 2013)
Father (including Step Father) Son’s wife Member of HUF Husband (or) Wife
Mother (including Step Mother) Daughter Daughter’s Husband Sister (Including Step Sister)
Brother (including step Brother) Son (Including step Son)

VI. Please tick (√) against the appropriate box

<- - - - - - - - - - - - - - - - - - Limit Category - - - - - - - - - - - - - - - - - - >

LRS NRO Net No Others
Customer Category
$ 250 K $ 1 Mio Salary Limit ( Mention the Limit in USD )

Resident Indian

NRI / PIO

a) NRE / FCNR A/c

b) NRO A/c of an NRI / PIO

Foreign National

a) Foreign Tourist

b) Employed in India

Trust / Association / Society / Club

Others

If Limit Category “Others” is chosen, then enclose necessary supporting documents.

 Retail Outward Remittance Application - A2 Cum LRS Declaration
VI. Furnish below if a message to be sent along with wire transfer on your behalf

VII. Source of Funds (only for transfer from NRO accounts)

Sl No Source of Funds Amount (INR)

Please add a separate sheet for more Sources of Funds to declare

Declaration (Under FEMA 1999)

* I/we hereby declare that the total amount of foreign exchange purchased from or remitted through all sources in India
during this financial year including this application is within overall limit of the Liberalised Remittance Scheme prescribed
by the Reserve Bank of India and certify that the source of funds for making the said remittance belongs to me and the
foreign exchange will not be used for prohibited purposes.
* The total amount of foreign exchange purchased from or remitted through, all sources in India during this financial year
including this application is within USD ________________________________________(USD __________________) the annual
limit prescribed by Reserve Bank of India for the said purpose.
* Foreign exchange purchased from you is for the purpose indicated above.
* The above remittance is NOT for investment / purchase of Bitcoin/Cryptocurrencies/Virtual Currencies (such as Ethereum,
Ripple, Litecoin, Dash, Peercoin, Dogecoin, Primecoin, Chinacoin, Ven, Bitcoin or any other virtual
currency/cryptocurrency/bitcoin).
* The above remittance is NOT for investment in units of mutual funds/shares or any other capital instrument of a company
dealing in Bitcoins/Cryptocurrency/Virtual Currencies.
* The source of funds for the proposed Remittance is NOT proceeds from redemption of investment in Cryptocurrency
/Bitcoins/Virtual Currencies and also end use of.
* I confirm that the aforesaid declarations and statements are true and correct to the best of my knowledge and belief.
* I/ We hereby declare that the transaction mentioned above doesn’t involve, and is not designed for any purpose for which
the drawing of foreign exchange is prohibited under rule 3 of the FEMA Current A/c transactions Rules, 2000 read with
schedule I therefore of Viz,
1. Travel to Nepal & or Bhutan
2. Transaction with a person resident in Nepal or Bhutan
3. Remittance out of lottery winnings
4. Remittance of Income from Racing / riding etc. or any other hobby.
5. Remittance for purchases of Lottery tickets, banned or prescribed magazines, football pools, sweep stakes,
schemes involving money circulations, securing prize money awards etc.
6. Payment of commission on exports made towards equity investments in joint ventures / wholly owned
subsidiaries abroad of Indian Companies
7. Remittance of dividend by any company to which the requirement of dividend balancing is applicable.
8. Payment of commission on export under rupee state credit route except commission up to 10% in invoice value
of exports of Tea & Tobacco.
9. Payment related to “Call back services” or telephones.
10. Remittance of interest income on funds held in non-resident special rupee a/c schemes.
* I / We, being a person(s) resident outside India, hereby declare that under Sec 4(b) of FEMA Permissible Capital A/c
Transaction regulation, 2000, the transaction mentioned above doesn’t involve and is not designed for any repatriation
outside India out of the proceeds of any investment in India, in any form, in any Company, Partnership firm (or) Proprietary
concern or any entity, whether incorporated or not, which is engaged or proposes to engage
a. In the business of chit funds or
b. As Nidhi company or
c. In agricultural or plantation activity, or
d. In real estate business, or construction of farm houses (real estate business shall not include development of
townships construction of residential / commercial premises roads or bridges), or
e. In trading and transferable development rights (TDRs)
* I / We being a person(s) resident outside India, hereby declare that no portion / part of outward remittance represents
interest on refunds of funds received from outside India for purchase of shares in India. Updated list of prohibited
transactions under FEMA can be accessed on ICICI Bank website (www.icicibank.com).
* (Strike out whichever is not applicable)
Other relevant declarations:
• I/we hereby declare that the purpose and transaction details as mentioned above are true to the best of my knowledge
does not involve, and is not designed for the purpose of any contravention or evasion of the provisions of the FEMA, 1999
or any rule, regulation, notification, direction or order made there under. I/We agree that I/We shall be responsible and
liable for any incorrect detail provided by me/us.
• 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 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.
• 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 in the disbursement of such funds including the withholding of such funds by
the correspondent and/or beneficiary banks. 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.
• 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.
• 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.
• 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.
• I hereby declare that where the cumulative amount of remittance under the Liberalized Remittance Scheme (LRS) exceeds
INR 7,00,000.00 in the current financial year, then a Tax Collected at Source (TCS) shall be charged at 5% on the amount of
remittance exceeding INR 7,00,000.00.
• In the event where the amount has remitted for the purpose of pursuing education through a loan obtained from a specified
financial institution in India, then the rate of applicable TCS shall be 0.5% on the amount excess of INR 7,00,000.00.
• I hereby declare to maintain sufficient balance in my account with ICICI Bank for deduction of the TCS at the applicable rate.
• I understand that my failure to maintain sufficient balance for processing the transaction and deduction of TCS in my
account may result in the transaction not being processed and I shall not hold ICICI Bank liable for the same and I authorize
ICICI Bank to debit my account at a subsequent date for deduction of the amount of TCS, as applicable.
• I hereby confirm to furnish a copy of my Permanent Account Number (PAN) / Aadhaar number to ICICI Bank, failing which
TCS would be collected at source at higher rate, as may be applicable.

Terms and Conditions related to CCIL:

1. Deal booked on CCIL Platform has to utilized for underlying forex transactions only.
2. All unutilized deal will be cancelled on maturity and loss arising out of cancellation will be recovered from customer’s
account. Gains, if any, arising out of such cancellation will not be passed on to the customer.
3. ICICI Bank has the right to reject the transaction request, on following grounds:
• In case of incorrect Deal number shared by the customer; or
• Deal unavailability in our system, due to expired deal / already utilized deal
4. Deals beyond maturity won’t be acceptable.
5. Each deal will be considered separate and in case of reversal there won’t be any netting off the deals.
6. Separate deal has to be booked for each product (e.g. for Remittance & Travel Card) and combined deal could not be
adjusted for multiple transactions.
7. Once the deal is booked on CCIL platform, client will be fully responsible for the utilization of the deal with the settlement
bank.
8. Deal booked and underlying request should be of same currency.
9. Client needs to submit documents along with the transaction. Outward deal to be utilized same day and inward deal to be
utilized on or before maturity.
10. Deal done through CCIL cannot be utilized for online reload or refund of travel card and physical currency.
11. The customer has to abide by all the Terms & Conditions of CCIL for trading in FX Retail platform.
 Retail Outward Remittance Application - A2 Cum LRS Declaration

To be filled in by residents only if the remittance is made under LRS

Declaration for purchase of Foreign Exchange under
the Liberalised Remittance Scheme (LRS) of USD 250,000 for Resident Individuals
Mandatory details to be provided for remittance under LRS

Source of funds for remittance under LRS

Details of the remittances made/transactions effected under the Liberalised Remittance Scheme in the current financial year
(April - March) ...............
SN Date Amount Name and Address of AD Branch / FFMC through which the transaction has been effected
1
2
3
Please add a separate sheet for more details of remittances to declare

I / We hereby declare that the total amount of Foreign Exchange purchased from (or) remitted abroad through all sources in
India during the financial year as given above, including utilization of the said limit on account of Loan extended or gift made
in Indian Rupees credited to NRO A/c of Non Resident Close relative(s), is within the limit of USD 250,000/- (US Dollar Two
Lakh Fifty Thousand Only), which is the limit prescribed by RBI for the purpose and certify that the source of funds for making
the said remittance belong to me and will not be used for prohibited purposes. Foreign exchange purchased from you is for
the purpose indicated above.

I / We, being a person(s) resident in India, hereby declare that for transactions done under the Liberalised Remittance Scheme
(LRS) for resident individuals, issued and amended by RBI from time to time, is not in the nature of remittance for margin calls
to overseas exchanges / overseas counter parties under this scheme.

Please tick the check-box if the remittance is made under purpose of Investment in shares
(Applicable for residents only)

I / We accordingly confirm as under:

This remittance is towards Investment in Equity and not for trading in forex or any other margin-based trading or any other
purpose prohibited as per the terms and conditions of the Liberalised Remittance Scheme for resident Individuals.
That the investment is in the shares of an existing company and is not intended to create a Joint Venture or Wholly-Owned
Subsidiary outside India*.
I/we also confirm that the remittance is towards purchase of shares of a foreign company and not in the shares of an Indian
company
*Incase your investment is into Joint Venture or Wholly Owned Subsidiary outside India, please inform the Bank official
accordingly.”

.............................................................................................
Signature of Remitter / Guardian in case of Minor

................................................................................
Date ………………….… Signature of Remitter / POA (or) Mandate Holder / Guardian in case of Minor
(The signature by mandate holder will be accepted only for Non resident A/c holders where mandate is duly registered with the Bank )

I certify that I have verified the Customer’s signature as per Bank records and retained the originals of all the scanned docu-
ments and forms submitted by the remitter for the above transaction.

I also certify that in case of LRS the remittance is not being made by / to ineligible entities and that the remittance is in
conformity with the instructions issued by the Reserve Bank from time to time under the Scheme.

Name & Employee ID Date & Place Bank Stamp & Employee Signature
 Retail Outward Remittance Application - A2 Cum LRS Declaration
(For Office Use Only)
Annexure-II
KYC Certification

(To be filled and scanned only in case of remittance by non ICICI Customer)

I confirm having met Mr./Ms./Mrs. _______________________________ at the Branch / other location (specify)

Further, I confirm having verified the copies of below KYC documents (as applicable) with the originals produced by the applicant and that the
applicant has signed the documents in my presence.

ID Proof

Address Proof

Name of the Bank official __________________________________________________________ Employee No. ____________ Designation __________

Date : _______________ Signature of the Branch Official and Branch stamp

Name of BM / BOM authorizing KYC certification above _________________________________________________ Employee No. ________________

Date : ______________ Signature of the Branch Official and Branch stamp

Details of INR amount credited to the pool a/c (Incl. of Charges + GST) _________________________________________________________________

Finacle Tran ID. ___________________________________________ IBR No. ________________________________________________________________

Date of credit _____________________________________________ into Pool A/c No.0035SLORCBPC

(If the remittance is by way of accepting cash deposit then the amount should not exceed INR 50,000/-)

...........................................................................................................................................................................................................................................

List of Approved Currencies for sending TT (or) DD Annexure-III

CURRENCY TT DD CURRENCY TT DD CURRENCY TT DD

US Dollar (USD)   Hong Kong Dollar (HKD)   Saudi Arabian Riyal (SAR)  
Great Britain Pounds (GBP)   New Zealand Dollar (NZD)   Qatari Riyal (QAR)  
Euro (EUR)   Japanese Yen (JPY)   Arab Emirates Dirham (AED)  
Canadian Dollar (CAD)   Swiss Francs (CHF)   Danish Kroner (DKK)  
Australian Dollar (AUD)   Swedish Kroner (SEK)   Norwegian Kroner (NOK)  
Singapore Dollar (SGD)   South African Rand (ZAR)   Thai Bhat (THB)  
Omani Rial (OMR)   Bahraini Dinar (BHD)  