APP.

V 118

FORM – R

Foreign Exchange Regulation Act, 1947

DECLARATION IN RESPECT OF RECEIPTS ABOVE $ 10,000/- FOR PURPOSE

OTHER THAN EXPORT & FAMILY MAINTENANCE

I/We advise having received foreign Exchange from:

(a) Name & Address of the Immediate Remitter: __________________________________
(b) Residence Country of Immediate Remitter: __________________________________
(c) Status of Immediate Remitter:
(Ultimate Controlling Parent (UCP)/ Head office, Branch,
Agent, Subsidiary, Associate, Individual etc.) __________________________________
(d) Name of Ultimate Controlling Parent (UCP),
if different from (a): __________________________________
(e) Residence Country of
Ultimate Controlling Parent (UCP): __________________________________
for the purpose viz.: _________________________________________________________
purpose code (insert the relevant code from the Code Guide):

amounting to _______________________________________________________________
(Name of currency and amount in figures and words)

Name of the Beneficiary: _________________________________

Principal Business: _________________________________
National Tax Number: _________________________________
Address of the Beneficiary: _________________________________

(Signature of the Beneficiary or his banker) (Stamp & Signature of Authorized Dealer)
 APP. V 107

SCHEDULE J/O-3

Period ……………………………………………………………..
Authorized Dealer ………………………………………………….
Currency ………………………………………………………….

Code Number
From NTN of the Country of the Status of the Country of Ultimate
Serial R/IRV Amount Purpose Beneficiary Immediate Immediate Controlling
No. Number . Remitter Remitter* Parent/Head office**
1 2 3 4 5 6 7 8

Total

* UCP or Head office or ultimate remitter = 1, Branch = 2, Subsidiary = 3, Associate = 4, Agent/bank = 5,

Individual = 6
** Insert the code of country of the Ultimate Controlling Parent (UCP)/Head office if the immediate remitter in
Col 7 is an agent, subsidiary, branch, associate of the UCP .

Coded by: …………………...

Checked by: …………………..
Stamp & Signature of Authorized Dealer