Third-Party / Family Member Payment Declaration — Declaration Format

Date:

Transaction Reference No.:

Traveller / Applicant Details

Name:

Passport No.:

PAN:

Purpose of Travel / Remittance:

Foreign Currency and Amount:

Person Making the Payment

Name:

Relationship with Traveller:

PAN:

Bank Account No.:

Name of Bank:

Payment Mode:NEFTRTGSIMPSChequeDemand DraftOther

Joint Declaration

We hereby declare that:

The person making the payment is the traveller’s:

FatherMotherSpouseSonDaughterBrotherSisterHead of FamilyEmployer / Sponsoring CompanyOther:

The payment is being made voluntarily for the bona fide foreign exchange requirement of the above traveller / applicant.
The funds are from legitimate and explainable sources and are not borrowed or received from any undisclosed third party for undertaking this transaction.
The foreign exchange entitlement and LRS utilisation, wherever applicable, shall be accounted for against the traveller / applicant and not against the person making the payment.
The payment is not being made for purchasing foreign exchange on behalf of an unknown or unrelated person.
Both parties authorise the company to verify the relationship, bank account, source of funds and transaction particulars.
Both parties accept responsibility for the correctness of the information and documents submitted.

Documents Submitted

Traveller’s PassportTraveller’s PANPayer’s PANPayer’s Bank StatementRelationship ProofSponsorship LetterCompany AuthorisationOther:

Traveller’s Signature

Payer’s Signature

Payer’s Mobile No.

For Office Use

Relationship verified through:

Payment received from permitted source:YesNo

Verified by:

Authorised Signatory: