Certificate of foreign inward remittance

Part-A

1.

Details of the beneficiary

(i)

Name

(refer Note 1)

(ii)

Address

(refer Note 2)

(iii)

Permanent Account Number

2.

Tax year

Part-B

3.

Certificate number

4.

Details of bank account of the beneficiary

(i)

Account number

(ii)

Name of the bank

(refer Note 1)

5.

Details of the remitter

(i)

Name

(refer Note 1)

(ii)

Address

(refer Note 2)

6.

Details of the remitting bank

(i)

Name

(refer Note 1)

(ii)

Address

(refer Note 2)

7.

Mode of remittance

8.

Transaction ID

(or Demand Draft/ Telegraphic Transfer/Money transfer No)

9.

Transaction date

dd/mm/yyyy

10.

Foreign currency amount

11.

Rupee equivalent

12.

Exchange rate applied

13.

Purpose of remittance

(as stated by remitter /beneficiary)

Certificate by the beneficiary bank

It is certified that the payment above has been received in convertible foreign exchange and not under any special trade or payments agreement, and that the reimbursement is obtained in a manner approved by Reserve Bank of India.

Signature of the Bank Manager Date:

Place:

Name:

Designation:

Address:

Certificate by the assessee

I (name), holding Permanent Account Number , hereby certify that the above particulars

contained in the certificate are true and correct to the best of my knowledge and belief and nothing has been concealed therein.

Signature of the assessee

Name:

Date:

Place: