(i)

The form should be completed and submitted to the concerned Regional Office of Reserve Bank before 15th January each year.

(ii)

If there are no shares to declare, a NIL return should be submitted.

(iii)

If the space provided in the form is not sufficient, the required information may be given in separate sheets.

(iv)

In cases where shares are held with a bank/institution in India or abroad, the name and address of the bank/institution should be stated at the footnote.

(v)

Separate return should be submitted in respect of each JV/WOS by each of the Indian share holders/promoters independently.

1.

Name and address of the

holder of shares

:

2.

Name and address of the

overseas JV / WOS

:

3.

Details of GOI / RBI

approval number and date

:

4.

Details of share(s) held [Amount in Foreign Currency (FC) only]

Description

No. of

Face value

Total

Manner in

RBI Holding

of shares

shares

of each

value

which shares

Licence No.

held

share

were obtained

and date

1

2

3

4

5

6

5.

Details of dividend repatriated : (Amount in FC only)

Description of

Total Value

Accounting

Rate of

Amount of

shares on which

of such

year to which

dividend

dividend

dividend has

shares

dividend is

earned*

been earned

related

1

2

3

4

5

Total amount

Details of bank

of dividend

certificates

Remarks

repatriated*

produced

6

7

8

6.

Any other relevant information :

DECLARATION

We hereby declare that :-

(a)

the particulars given above are true and correct to the best of our knowledge and belief and

(b)

we do not have any other foreign currency shares issued by the concerned JV / WOS abroad.

Place :

Date :

D

D

M

M

Y

Y

Y

Y

(Signature of authorised official)

Stamp/

Name : ____________________

Seal

Designation : _______________