Annex – 3
[Annex to A.P. (DIR Series) Circular No.90 dated March 06, 2012]

Application cum Declaration for purchase of foreign exchange under the
Liberalised Remittance Scheme of USD 200,000 for Resident individuals

(To be completed by the applicant)
I. Details of the applicant
a. Name …………………………..
b. Address…………………………
c. Account No……………………..
d. PAN No………………………….
II. Details of the foreign exchange required
1. Amount (Specify currency)………………………………
2. Purpose ……………………………………………………
III. Source of funds: ………………………………………….
IV. Nature of instrument
Draft………………………..
Direct remittance…………
V. Details of the remittance made under the Scheme in the financial year
(April- March) 20__ – 20__
Date :………………
Amount :………….
VI. Details of the Beneficiary
1. Name ……………………..
2. Address ……………………
3. Country ……………………
4*. Name and address of the bank……………………….
5*. Account No……………………………………………..
(* Required only when the remittance is to be directly credited to the bank account of the beneficiary)
This is to authorize you to debit my account and effect the foreign exchange
remittance/ issue a draft as detailed above (strike out whichever is not applicable).
Declaration
I, ………………. …………(Name), hereby declare that the total amount of foreign
exchange purchased from or remitted through, all sources in India during the
financial year as per item No. V of the Application, including utilisation of the said
limit on account of loan extended or gift made in rupees credited to NRO account of
non-resident close relative(s), is within the limit of USD 200,000/- (US Dollar Two 33
hundred thousand only), which is the limit prescribed by the Reserve Bank for the
purpose and certify that the source of funds for making the said remittance belongs
to me and will not be used for prohibited purposes.
Signature of the applicant(Name)
Signature of the natural guardian of the applicant @
(Name)
@ Where the applicant is minor, the application should be countersigned by minor’s
natural guardian
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:
Place:
Signature:
Date:
Stamp and Seal
Signature of the applicant
(Name)
34