(CURRENCY NAME)

(Currency Code)

Return of transactions for the fortnight ended

(Date DD-MM-YYYY in Numerals)

Name of AD

AD Code No

Address of AD

Licence No.

Serial No.

I.

Outflows

A.

Sales to Public against Imports into India

(i)

Below the equivalent of Rs.5,00,000/-

(Supported by Forms A1)

(No. of Forms

)

(ii)

Equivalent of Rs.5,00,000/- and above

(Supported by Forms A1)

(No. of Forms

)

Total of I A(i) and IA(ii)

B.

Sales to Public against Imports into other countries

(i.e. Intermediary Trade)

(Supported by Forms A2 - No. of forms

)

C.

Sales to Public for purposes other than Imports

(i)

Below the equivalent of Rs.5,00,000/-

(Supported by Forms A2/ statement)

(No. of Forms

)

(ii)

Equivalent of Rs.5,00,000/- and above

(Supported by Forms A2/ statement)

(No. of Forms

)

Total of I A(i) and IA(ii)

D.

Sales to other Authorised Dealers in India

Total Outflows (Total of IA, IB, IC and ID)

(For A Category Branches only)

*

*

E

Sales to Reserve Bank of India

*

*

F.

Sales to overseas banks and branches

*

(Supported by Statement)

*

*

G.

Aggregate sales at Branches (Reporting directly to

*

Reserve Bank) by adjustment through Head Office/ Link Office

*

Total of I A to I G

H.

Notional sales relating to reversal of

overdue export bills (Form A2 should

Not be completed) The total of such sales

should be shown separately here

II.

Infows

A.

Purchases from Public against exports

(i)

Against GR/PP/SOFTEX Forms of

Which

(a)

Bills negotiated under L/C and

bills purchased & discounted

(b)

Bills for collection realised

(ii)

Advance receipts which will be

covered later by GR/PP/SOFTEX

Forms

Total of II A(i)(a), II A(i)(b) & II A(ii)

Note:

ENC Statement (in duplicate)

alongwith duplicate GR/PP/SOFTEX

forms and SCH 3 should be

attached to R-Return.

B.

Purchases from Public against third country exports (i.e.

intermediary trade not covered by GR/PP/SOFTEX Forms)

C.

Purchases from Public other than against exports

(i)

Below equivalent of Rs.1,00,000/-

(ii)

Equivalent of Rs.1,00,000/- and above

Total of II C(i) and II C(ii)

Note:

In respect of item IIC(ii) a supplementary statement

with bifurcating lines between two purchases) should be

attached as in the prescribed proforma.

D.

Purchases from Authorised Dealers in India

Total inflows(Total of IIA,IIB,IIC and IID)

(For A Category Branches only)

*

*

E

Purchases form Reserve Bank of India

*

*

F.

Purchases form overseas banks and branches

*

(Supported by Statement)

*

*

G.

Aggregate Purchase at Branches (Reporting directly to

*

Reserve Bank) by adjustment through Head Office/ Link Office

Total of II A to II G

H.

Purchase relating to reversal Export

bills

The total of such purchases should be

Shown separately here.

Amount

Debit

Credit

III.

Opening Balance (Closing bal.of previous period)

A. Cash Balance

B. Suspense Account Balance

C. Deposits with/from other Authorised Dealers in India

D. Deposits with Reserve Bank of India

E. Fixed Deposits

F. Treasury Bills/Treasury Deposits

G. Securities and Shares

H. Foreign Currency Loan (Outstanding)

Total of IIIA to IIIH

IV.

Closing Balance

A. Cash Balance

B. Suspense Account Balance

C. Deposits with/from other Authorised Dealers in India

D. Deposits with Reserve Bank of India

E. Fixed Deposits

F. Treasury Bills/Treasury Deposits

G. Securities and Shares

H. Foreign Currency Loan(Outstanding)

Total of IVA to IVH

Note:

Authorised Dealers should ensure that

Opening Balance + All Inflows - All

Outflows tally with Closing Balance.

V.

Aggregate Balances in

A. EEFC Accounts

B. EFC Accounts

C. RFC Accounts

D. ESCROW F.C. Accounts

E. FCNR(B) Accounts

F. Other F.C. Accounts

We hereby certify that

(a)

the figures reported in the above Return are true and correct;

(b)

all the transactions effected by us and by our branches not submitting independent Returns during the reporting period to which this Return relates have been reported in this Return;

(c)

all the remittance forms alongwith SCH 1 and SCH 2, \ENC statement and all GR/PP/SOFTEX forms alongwith SCH 3 covering the transactions effected during the reporting period have been attached herewith.

(d)

no remittance forms and GR/PP/SOFTEX forms pertaining to any of the previous reporting periods of the current reporting period are outstanding with us;

(e)

a supplementary statement in respect of item II(ii) of the Return is enclosed;

(f)

all the Returns pertaining to the earlier periods have been submitted to the Reserve Bank and

(g)

the transactions of the offices/branches which are independently submitting Returns and adjusting through Head Office/Link Office account with us have been incorporated as branch sales/purchases in our Return.

Stamp

#

Seal

(Signature)

Name

Date:

Designation

[#

This certificate must invariably be signed by the official holding charge of the branch for the time being or by person of status not lower than that of Scale IV Officer.]