Xotik Travel and Forex Private Limited

REGD. OFF. : 203-204, 2nd Floor, Geeta Enclave, Vinoba Marg, C-Scheme, Jaipur-302001,
Rajasthan Ph.: 0141-4027925, 4110696 Email: [email protected] Website: www.xotik.in
AD - II License No. FE.JP.AD CAT-II 02/2019
FORM A2
Branch VIJAYAWADA Application cum Declaration (To be completed by the Applicant)

Application for drawal of Foreign Exchange___________________________________________________________________

I. Detail of the Applicant:

Full Name : MOHAN SRI RAM ALURU

Address : D.NO:1-58/A, KANASANAPALLI VILLAGE, AGIRIPALLI MANDAL, KRISHNA – 521212, A.P.INDIA.

City : AGIRIPALLI PIN : 521212 Telephone No : Email Address: [email protected]

II. Passport Details:

U9483155 VIJAYAWADA 03-02-2021 02-02-2031

III. Visa/Ticket Reference No.: Date of Journey

IV. Payment Details :

Mode of Payment: Cash / Cheque / Pay Order / Demand Draft No: S5078229 Dt : 24-05-2022 for Rs. 629900/-

(Bank Name & Branch) : ICICI BANK PAN NO. DYHPA4230C

VI. Foreign Exchange Issued

a) Draft / Fund Transfer (Remittance ) Remittance request and documents in support attached

I want to remit money for Mr./ Ms.my MOHAN SRI RAM ALURU ( student name/traveller’s name) and request you to transfer
funds CAD 10250 (currency name and quantity ) in favour of ( Beneficiary’s name) MOHAN SRI RAM ALURU
(University’s name / tour agent’s / Student name
Beneficiary’s Address: D.NO:1-58/A, KANASANAPALLI VILLAGE, AGIRIPALLI MANDAL, KRISHNA – 521212, A.P.INDIA
Name & address of Bank: THE BANK OF NOVA SXOTIA
Beneficiary’s Account No: 000000106941354
Other Details,--swift code / FED Wire / Sort Code: NOSCCATT

Detail of remittances transactions effected under the LRS scheme in the current financial year April _2022_ to March 2023

S.NO. DATE AMOUNT NAME AND ADDRESS OF AD BRANCH / FFMC THROUGH WHICH THE
TRANSACTION EFFECTED

b) Release of exchange
Traveller’s Cheque____________ _____Foreign Currency Notes ________________Pre Paid Cards__________________________

Declaration (under FEMA 1999)

Signature of the Applicant:
I MOHAN SRI RAM ALURU hereby declare that this transaction does not involve and is not designed for the purpose of
any contravention or evasion of provisions u/s 10(5) chapter III FEMA 1999 or of any rule, regulations, notification, direction or order made there
under. I also herby agree and undertake to give such information/documents as will reasonably satisfy you about this transaction in terms of the
above declaration. I further confirm that the foreign exchange released for the above mentioned purpose will be used within 60 days of purchase. In
case it is not possible to use the foreign exchange within the period of 60 days, same will be surrendered to an authorized person. I also understand
that if I refuse to comply with any such requirement or make only unsatisfactory compliance therewith, the Authorized person shall refuse in writing
to undertake the transaction and shall if it has reason to believe that any contravention / evasion is contemplated by me / us, report the matter to
Reserve Bank of India. I declare that the total amount of foreign exchange purchased from or remitted through, all sources in India during this
financial year including this application is within USD 2,50,000 or its equivalent (USD Two Lacs Fifty Thousand or its equivalent) which is the limit
prescribed by the Reserve Bank of India for the purpose and certify that the source of funds for making the said remittance belongs to me and the
foreign exchange will not be used for prohibited purposes.

Place : VIJAYAWADA Signature :

Name : MOHAN SRI RAM ALURU

 TCS DECLARATION CUM UNDERTAKING FOR INDIVIDUAL UNDER LIBERALISED REMITTANCE SCHEME
& FILING OF INCOME TAX RETURNS

The Manager
XOTIK TRAVEL AND FOREX PRIVATE LIMITED
VIJAYAWADA Branch

Dear Sir,

This is to certify that I/we want to purchase/remit foreign exchange for Mr/Ms MOHAN SRI RAM ALURU my
overseas travel to (country) CANADA for personal/tourism purpose.

In compliance to provision of Section 2206CCA2, I/we confirm that we have filed income tax return for Assessment
year ____________& Assessment year____________(last two years). Further I/we confirm filing the income tax
return for Assessment year __________________(current assessment year) before due date.

OR

I/we confirm that our aggregate tax deduction at source and tax collected at source does not exceed Rs. 50000/- or
more for the Financial Years ________ , ___________ and _____________ each ( last three years.

I/we having Pan no DYHPA4230C hereby declare that the transaction details are specifically mentioned in the
Declaration does not involve, and to the best of our knowledge and belief is not designed/intended or will result in
any contravention or evasion of the provisions of the INCOME TAX ACT, 1962 of any rule, regulation, notification,
direction or order made there under.

As per the new provision under the Liberalized Remittance Scheme (LRS) which come into effect from Ist October
2020 I/we are aware that as per income tax laws, TCS is applicable on purchase /foreign remittance at 5% under
the Reserve Bank of India’s (RBI) LRS, if the total amount remitted exceeds Rs 7 lakhs within a financial year the TCS
amount will be applicable on the amount exceeding the existing threshold. I hereby agree for the TCS collection
on the proposed transaction, if applicable.

To be filled only in case of remittance being done through Education Loan:

In case of remittance out of education loan obtained, I submit that the loan has been taken from the following enti
ties as mentioned under section 80E of the Income tax Act, 1961 (“the Act”)(tick as appropriate from the below)

________Financial institution - A banking company to which the Banking Regulation Act, 1949 (10 of 1949) applies
(including any bank or banking institution referred to in section 51 of that Act);

_____________Any other financial institution which has been notified by the Central Government in the Official Gazette – As on
date, Credila Financial Services Private Limited has been notified as a recognized financial institution.

I attach herewith loan disbursement letter obtained from _________________________(name of financial Institution ) having
Pan_____________________

I further confirm that the amount being remitted outside India is in the nature of education loan taken from „financ
ial institution‟ as defined under section 80E of the Act and hence, tax at source required to be collected on the
above remittance of Foreign Exchange of ______________________by the Authorized Dealer at 0.5% as prescribed
under section 206C(1G) of the Act.
I/We shall indemnify, defend and hold harmless to XOTIK Travel And Forex Pvt. Ltd. from and against any liability
that may occur, arising from or relating to:-
(i) A breach or non-performance by ___________(Relationship-Individual name) with any of the terms,
conditions, covenants, representations, undertakings, obligations or warranties under the provisions ,
rules , regulations of Income Tax Act.
(ii) The misrepresentations, willful misconduct or negligence, in the performance of its obligations under
the Income Tax Act.
Detail of the remittances/foreign exchange made/transactions effected/executed under the LRS scheme in the
current financial year April 2022 to March 2023

S. NO DATE AMOUNT in INR

NAME AND ADDRESS OF AD BRANCH/FFMC THROGH
WHICH THE TRANSACTION HAS BEEN EFECTED

I/We further declare that the total amount of foreign exchange purchases from or remitted through all sources in India
during this financial year including this application is within USD 2,50,000.(The annual limit prescribed by Reserve Bank Of
India). I/We also hereby agree and undertake to give such information/ documents as will reasonably satisfy you about this
transaction in terms of the above declaration and this transaction does not involve and is not designed for the purpose of
any contravention or evasion of the provisions of FEMA or any rule, regulation, notification, direction or order issued there
under.

Thanking You

Full Signature
Name MOHAN SRI RAM ALURU
Copy of Govt. issued Id Proof with address
PASSPORT / AADHAAR : U9483155
D.NO:1-58/A, KANASANAPALLI VILLAGE, AGIRIPALLI MANDAL, KRISHNA – 521212, A.P.INDIA.

Date: 24.05.2022

Place: VIJAYAWADA