Citi India consumer banking customers are now served by Axis Bank.
Citi India has transferred ownership of its consumer banking
business to Axis Bank (registration number L65110GJ1993PLC020769). Consumer banking customers can continue to use all
existing Citi products and/or services, branches, ATMs, internet banking and Citi Mobile® App as usual. Axis Bank is the provider
of Citi branded consumer banking products in India temporarily and Citi India is providing certain services in respect of those
products.The trademarks “Citi”, “Citibank”, “Citigroup”, the Arc design and all similar trademarks and derivations thereof are used
temporarily under license by Axis Bank from Citigroup Inc. and related group entities.
I/We
SOURABH�ROY
(Name of applicant remitter)
PAN No.
BTTHN0610N Remitter Details
(For remittances exceeding USD 25,000 and for all capital account transactions)
Address :
FLAT�NO.,�STREET�NAME authorise
BRANCH�NAME
(Name of AD branch)
Amount (specify currency) : INR�50,00,000 Amount of remittance in INR
To debit my Savings Bank/Current/RFC/EEFC A/c. No.
5050505050 together with their charges and Account number to be debited
*
SOURABH�ROY
BANK�OF�AMERICA Beneficiary’s Bank Name and address
STREET�AND�AREA�NAME
0434�0434�0434
Beneficiary’s account number
*
* Issue foreign currency notes for :
*(Strike out whichever is not applicable) for the purpose/s indicated below.
If the source is Cash gift ,then “Yes”
For all other source “NO”
Whether under LRS
(Yes/No)
NO 50000 AS�MENTIONED�IN�ANNEX-I�
As per the Annex
Remitter should put a tick (√) against an appropriate purpose code. In case of doubt/ difficulty, the AD bank should be consulted. Appropriate Purpose code and
Corresponding Description to be
Chosen from the 3rd sheet or
as per 15 CA and CB form.
VER 1.6/FORM A2/WPC/03-17
Remitter’s full name
# I,
SOURABH�ROY (Name), hereby declare that the total amount of foreign exchange purchased from
or remitted through, all sources in India during the financial year including this application is within the 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.
Details of the remittances made/transactions effected under the Liberalised Remittance Scheme in the current financial year
(April- March) ...
Name and address of AD branch/FFMC through
Date Amount
which the transaction has been effected
To be filled only if LRS is “YES”
If LRS is ‘Yes’, limit is USD 250,000;
For all other sources, limit is USD 1 million
Signature of the remitter
SIGNATURE
Signature of the Applicant
SOURABH�ROY Name of the remitter
0 1 0 3 2 0 1 7
Certificate by the Authorised Dealer:
This is to certify that 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 and designation of the authorised official Stamp and seal
2023
00 Acquisition of non-produced non-financial assets (Purchase of intangible assets
like patents, copyrights, trademarks etc., land acquired by government, use of
natural resources) –
Acquisition of non-produced non-financial assets (Purchase of intangible assets like
patents, copyrights, trademarks etc., use of natural resources) – Non-Government
07
Capital transfers (Guarantees payments, Investment Grand given by the government
/international organisation, 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 08
09 Charges for
the use of
intellectual
property n.i.e
10 Other Business
Services
Opening of foreign currency account abroad with a bank
01 Imports S0101 Advance payment against imports made to countries other than Nepal and Bhutan
S0102 Payment towards imports- settlement of invoice other than Nepal and Bhutan
S0103 Imports by diplomatic missions other than Nepal and Bhutan
S0104 Intermediary trade/transit trade, i.e., third country export passing through India
S0108 Goods acquired under merchanting / Payment against import leg of merchanting trade*
11
S0109 Payments made for Imports from Nepal and Bhutan, if any
02 Payments for surplus freight/passenger fare by foreign shipping companies
operating in India
12 Govt. not
included
elsewhere
(G.n.i.e.)
03
05 Construction
Services
06
16 Maintenance
and repair
services n.i.e
17 Manufacturing
services
(goods for
processing)
