Request Letter for Clean Outward Remittances

To
The Branch Manager,
ICICI Bank Ltd.,
Nehru Place Branch

We wish to make the following remittance for the purpose of S1099 (Other
Services not included elsewhere )

We hereby request you to remit/ issue a DD for the amount as per the
details given below :-

Amount to be remitted (in foreign AED 99,000

1.
currency)
23.05.2019
2.
Value Date
Kapil Arora
H.No. 19, Coperative Bank ki Gali,
3. Remitter’s Name & Address
Ward 8, Baran, Rajasthan, India-
325219
Warren Luyt
Trident Trust, Level 41, Mazaya
4. Beneficiary’s Name & Address
Business Avenue AA1 JLTT, Dubai,
United Arab Emirates, 000000
Bank Name: Commercial Bank of
Beneficiary’s Bank Account No., Banker’s Dubai
5.
Name & Address & SWIFT code IBAN: AE140230000001001477023
Swift Code: CBDUAEADDXB

6. Beneficiary’s Bank’s Correspondent Bank

Name, Address & SWIFT code
Other Services not included
Purpose of remittance ( the details to be elsewhere
7.
mentioned in SWIFT Message for
Beneficiary’s information)
To our Account
8. Foreign Bank Charges ( strike off
whichever is NOT applicable)
We request you to debit our EEFC Account No………….. for an amount of
……………… and the balance amount to our Cash Credit Account / Current
Account No………………. along with your charges.

The details of Forward Contract(s), if any, booked against this payment

is/are as follows –

Forward Contract Forward Contract Amount to be Utilised Due Date of the

No. & Date Amount for this remittance Contract

Documents enclosed:
1. Form A2
2. Proforma Invoice / Demand Notice of the Beneficiary duly signed by
Applicant
3. Other Documents as applicable ( Please refer the
Guidelines/Checklist enclosed) Please specify.

I/We agree and acknowledge:

The Bank may return or refuse to accept all or any part of a deposit or
credit to an Account or process a transaction, at any time, and will not be
liable to the Customer for doing so, even if such action causes outstanding
items to be dishonoured and returned, or payment orders to be rejected.
Refused deposits will be returned to the Customer.

Bank uses the services of correspondent banks to provide various

services. Bank will take due care to protect the interest of its customer,
but shall not be responsible if there are any losses/liabilities which arise as
a result of the action of the correspondent bank and/or any delay in
realization of cheques deposited.

Declaration – Cum – Undertaking Under Section 10(5) Chapter III of FEMA

1999

I/We hereby declare that the transaction the details of which are
specifically mentioned in this request letter 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 rules, regulation, notification, direction or
order made there under. 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 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 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
company.

Yours Truly,

Name and Signature of the Authorized Signatory