Travel Cancellation and Forex Refund Declaration — Declaration Format

Date:

Original Transaction Reference No.:

Customer Name:

Passport No.:

Original Travel Date:

Destination:

Details of Forex Purchased

Currency / Product:

Amount Purchased / Loaded:

Amount Used:

Amount Being Returned / Refunded:

Declaration

I declare that my proposed travel has been:

CancelledPostponedRescheduledPartially completedChanged to another destination

Reason

I request:

Encashment of unused currency notesCancellation / unloading of forex cardCancellation of remittance requestRefund of available balanceOther:

I confirm that:

The unused foreign exchange belongs to me.
The foreign exchange has not been sold, transferred or used by another person.
Any applicable cancellation charge, exchange difference, card charge, bank charge or administrative charge may be deducted.
Refund will be made to the permissible source / account after necessary verification.
Any related TCS adjustment or refund will be subject to the applicable tax procedure and records.
I have submitted the available cancellation, revised itinerary or supporting documents.

Customer Signature

For Office Use

Original payment source verified:YesNo

Refund mode:

Refund amount (₹):

Cancellation / other charges (₹):

Processed by:

Authorised Signatory: