Forex Card - Reload / Refund /

Wallet to wallet transfer form

Version - March 2023

Forex Card Details*
Mult i-currency Forex Card Axis Bank Club Vistara Forex Card Miles & More Axis Bank World Traveller Card

Forex Card No.* Customer ID

Date First Name* Middle Name Last Name*

Name* Mr. Mrs. Ms. Dr.

Tax Resident ial Status as per Income Tax Act, 1961* Resident Non-Resident
Minor Y N

Reload* (For reload request this section is mandatory)

Axis Bank Forex Currency Reload Amount Rs. Axis Bank Forex Currency Reload Amount (in Foreign Currency)
Details of Travel*
Country of Travel* 1.________________________________ 2.________________________________ 3.________________________________ 4.________________________________ 5.________________________________

Date of Travel Date of Return:

Purpose of Travel* Business Education Medical Holiday / Leisure Emigration Pilgrimage Others

Purpose Code Descript ion

Details of Foreign Exchange required*:

FCY Amount (in words)

Currency USD GBP EUR SEK CHF JPY HKD NZD

Forex Card Amt

Currency AUD CAD SGD AED SAR THB DKK ZAR

Forex Card Amount

*End use of funds (If amount is more than USD 5,000 equivalent _________________________________________________________________________________________________________________________________
Reason for mismatch in country of travel and currency loaded (only in case there is a mismatch)* _________________________________________________________________________

In case the applicant / nominee is a Minor # Details of Guardian and Declarat ion for Minor (Mandatory)
Full Name of Guardian Mr. / Mrs. / Ms.* First Name Middle Name Last Name

Type of Guardian* Father Mother Court Appointed Phone No. of the Guardian (in case applicable)

Address of the Guardian* _________________________________________________________________________________________________________________________________

Document proof of Guardian* ________________________________________________________________________________________________________________________________
Funder’s Passport Number/Driver's License/ Aadhaar Number (last 4 digits only) ___________________________________________________________________________________________________________
Expiry Date (Applicable only for Driver's License & Passport Number)
I wish to purchase a _________ denominated Forex Card for my ward, _____________________________________________ <name of the minor>. I declare that the funds being given
for the purchase of the Foreign Currency to be loaded on the card are being provided by me.
I hereby declare that the date of birth of the minor who is my ____________________ is ____ / _____ / ________ (dd/mm/yyyy) and I am his / her natural and lawful guardian
appointed by Court Order dt. ____________________________________________ (Copy enclosed). I state and confirm that the Forex Card is purchased for the actual use by the
minor and on behalf of the minor I conf irm that I shall be liable for the misuse of Forex Card and shall abide by all applicable regulations regarding the usage of
Forex Card. Yours faithfully,
Signature Guardian

(Signature of Guardian)

Declarat ion for Sole Proprietor (In case of a Sole Proprietor this declarat ion is mandatory)
I hereby declare that the currency being loaded on this Forex Card here does not exceed the LRS limit of my individual capacity and my Sole Proprietorship
capacity combined together for this f inancial year.

Name of the Applicant _________________________________________________________________________________________________________________

(Signature of applicant)

Refund* (for refund request this section is mandatory)

Forex Card Balance Amount Forex Card Refund Amount*

Axis Bank A/c No.*

(In case of ETB customer)
Other Bank A/c No.* _______________________________________________________________________________________________________________ IFSC Code*
(In case of ETB/NTB customer)

Wallet to wallet
From Wallet (Currency Type)

Amount (FCY)
To Wallet (FCY)

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 Request to Increase/Decrease limit or Enable/Disable channel (Amount to be mentioned in USD Equivalent only.)
ATM (Enable/Disable): USD ________________________ (Limit)

POS (Enable/Disable): USD ________________________ (Limit)

Ecom transaction (Online) (Enable/Disable): USD ________________________ (Limit)

Contactless (Enable/Disable): USD ________________________ (Limit)

Reason* ________________________________________________________
Please note: Ecom and contactless transaction limit should not be greater than POS limit

Documents Submit ted

Air Ticket / Visa Copy of Passport PAN Copy

Payment Mode* (Mandatory for New to Bank (NTB) Customer) (To be filled in case of Reload)

Cheque / DD Transfer from own Axis Bank Account Transfer from own other bank account

Other Bank Name* Other Bank Account*

Cheque / DD Number*

Debit Authority (For Axis Bank Account holder)*

I / We authorize you to debit my / our account number___________________________________________________ and effect the Forex Card funding, as detailed above, along with
your applicable charges i.e. Foreign Conversion Tax, Commission and Service Tax.

Signature of the Account Holder

Source of Fund* (The complete section is mandatory)

Salary Business Income Agriculture Investment Income Education Loan Others (In case of 'Others' please mention exact source*)

*Relation with person funding the Card Self Father (including Stepfather) Mother (including Stepmother) Son (including Stepson) Spouse

Son's Wife Daughter Daughter's Husband Brother (including Stepbrother) Sister (including Stepsister) *For list of close relatives, please refer to Section 1

Name of person funding the card* (This information is required only if the
card holder is not funding the card) PAN of person funding the card* (This information is required only if the
card holder is not funding the card).

Funders Residential Status* Resident Indian NRI PIO / OCI* Foreign National
Section 1: A person shall be deemed to be relative of another if, and only if, (a) they are members of a Hindu Undivided Family; or (b) they are husband and wife: (c) the one is related to the other in the manner indicated above:

OFAC Declarat ion*

I / We declare that the Forex Card so issued is not to be and shall not be used in countries under economic sanct ions for any purpose.

Signature of applicant
Name of the Applicant ____________________________________________________________________________________________________________

Declarat ion for purchase of Foreign Exchange under the Liberalized Remit tance Scheme of USD 250,000*
Details of the remit tances made / transact ions effected under the Scheme in the current f inancial year (April______ - March ______ )

Name and Address of AD branch /

Sr. No. Date Amount
FFMC through which the transact ion has been ef fected

1.

2.

3.

4.

5.

Sr. No. Whether under LRS (Yes / No) Purpose Code Descript ion

1. As per the Annex

2.

Declarat ion
I / We hereby declare that:-
Declarat ion under FEMA 1995 as per Form A2:
I / We hereby declare that:-
1. The total amount of foreign exchange purchased from or remit ted through all sources in India during this financial year including this applicat ion is within USD
2,50,000 (USD Two Lakh Fifty Thousand only) the annual limit prescribed by Reserve Bank of India for the said purpose #
2. Foreign exchange purchased from me is for the purpose indicated in sect ion Details of Travel (*Strike out whichever is not applicable).
Declarat ion-cum-undertaking under Sec 10(5), Chapter III of FEMA 1999.
1. I / We hereby declare that the transact ion details of which are ment ioned above does not involve, and is not designated for the purpose of any contravent ion
or evasion of the provisions of the aforesaid Act, or any rule, regulat ion, notif icat ion, direct ion or order made there under.

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 2. I / We also understand that if I / We refuse to comply with any such requirement or make only unsat isfactory compliance therewith, the Bank shall refuse,
in writ ing to understand the transact ion and shall, If it has reason to believe that any contravent ion / evasion is contemplated by me / us, report the mat ter to RBI
3. I / We also hereby agree and undertake to give such informat ion / documents as will reasonably sat isfy you about this transact ion, in terms of the above declarat ion.
Declarat ion under Liberalized Remit tance Scheme for Resident individuals:
1. I / We hereby declare that the total amount of Foreign Exchange purchased from or remit ted through, all sources in India during the f inancial year including
this applicat ion is within the overall limit of the Liberalized Remit tance Scheme prescribed by the Reserve Bank of India and cert ify that the source of funds
for making the said remit tance belongs to me and the Foreign Exchange will not be used for prohibited purposes.
2. I/We affirm that the residential status provided is true.
3. The remit tance would be ut ilized for permit ted Capital & Current Account transactions only.
4. I have not availed any loan / credit / borrowing for remit t ing under Liberalized Remittance Scheme for Capital Account transact ions
5. The remit tance is not being requested for transact ion not permissible under FEMA and those in the nature of remit tance for margins or margin calls to
overseas exchanges / counterparty are not allowed under the Scheme.
6. The Scheme is not available for capital account remit tance to countries identif ied by Financial Act ion Task Force (FATF) as non co-operat ive countries and
territories as available on FATF website www.fat f-gafi.org or as not if ied by the Reserve Bank.
7. The remit tance is not being sent for purchase of FCCBs issued by Indian companies in the overseas secondary market.
8. The remit tance is not being sent for trading in Foreign Exchange abroad.
9. I / We undertake to make all Capital A/c transact ions under LRS from Axis Bank only.
Declarat ion from Tour Operators
I / We conf irm that the remit tance is being made for travel arrangements of
1. Resident Individuals as per enclosed list. The remit tance made is within the limits prescribed by the Reserve Bank of India for the resident individuals under
the Liberalized Remit tance Scheme.
2. Foreign Tourists as per enclosed list. The amount of remit tance does not exceed the amount of ForeignExchange remitted to India by the Foreign Tourists.
General Declarat ion
1. The purpose and transact ion details as ment ioned above are true to the best of my knowledge.
2. I / We shall be responsible and liable for any incorrect detail provided by me / us.
3. The remit tance is not being requested for any purpose specif ically prohibited under Schedule I or any item restricted under Schedule II of Foreign Exchange
Management (Current Account Transact ion) Rules 2000.
4. The remit tance is not being sent directly or indirectly to Nepal and Bhutan.
5. The remit tance is not being sent directly or indirectly to these individuals and entities identified as posing significant risk of committing acts of terrorism as
advised separately by the RBI to the Banks.
6. The transact ion ment ioned above does not involve, and is not designed for any purpose for which the drawal of Foreign Exchange is prohibited under Rule 3
of the Foreign Exchange Management (Current Account Transact ions) Rules 2,000, read with Schedule I there of viz:
a. Remit tance out of lot tery winnings
b. Remit tance of income from racing / riding, etc. or any other hobby
c. Remit tance for purchase of lot tery t ickets, banned / proscribed magazines, football pools, sweepstakes, schemes involving money circulat ion, securing
price money / awards, etc.
d. Payment on commission on exports made towards equity investment in Joint Ventures / Wholly Owned Subsidiaries abroad of Indian companies
e. Remit tance of dividends by any company, to which the requirement of dividend balancing is applicable
f. Payment of commission of exports under the Rupee State Credit Route, except commission up to 10% of invoice value on exports of tea and tobacco
g. Payment related to “Call-back Services” of telephones
h. Remit tance of interest income on funds held in the Non-Resident Special Rupee Acount Scheme
i. Travel to Nepal and / or Bhutan
j. A transact ion with a person residing in Nepal or Bhutan
7. I / We agree that submission of request does not necessarily imply processing of the transaction. Axis Bank has full rights to reject the transaction based on
regulatory and internal guidelines.
8. I / We agree that in the event the transact ion could not be executed / debited to my / our account, after submit t ing the request for processing to the Bank on
account of insuf f icient / unclear balance at the t ime of execut ion of the transact ion in my / our account. Axis Bank shall not be responsible for not being able
to process the transact ion. Any exchange losses incurred in this connect ion, due to reversal of the forex deal, can be charged to my / our Axis Bank Account.
9. I / We agree that in the event the transact ion is cancelled or revoked by me / us after submit t ing the request for processing to the Bank, any exchange losses
incurred in this connect ion, can be charged to my / our benef iciary Banks.
10. I / We further agree that once the funds remit ted by me / us have been transmit ted by Axis Bank to the correspondent and / or benef iciary Banks, Axis Bank
shall not be responsible for any delays in the disbursement of such funds, including the withholding of such funds by the correspondent and / or benef iciary Banks.
11. I / We agree that once the funds are remitted by me / us have been transmit ted by Axis Bank intermediary bank charges may be levied by correspondent and
/ or benef iciary banks, which may vary from Bank to Bank.
12. I / We agree that in the event the transact ion being rejected by the benef iciary Bank, because of incorrect informat ion submit ted by me, any charges levied
by the benef iciary Bank or exchange losses incurred in this connect ion can be charged to my Axis Bank Account.
13. I / We further declare that the undersigned has the authority to give this applicat ion declarat ion and undertaking on behalf of the f irm / company. (Applicable
when the applicat ion / declarat ion / undertaking to signed on behalf of the firm / company)
14. I / We undertake that I / We will not remit payments directly / indirectly outside India in any form towards overseas Foreign Exchange trading through electronic
/ internet trading portals. I am aware that effect ing such transact ions would make me / us liable to be proceeded against with for contravent ion of the Foreign
Exchange Management Act (FEMA), 1999 besides being liable for violat ion of regulat ions relat ing to Know Your Customer (KYC) norms / Ant i Money
Laundering (AML) standard.
15. I / We confirm that we are aware of Axis Bank Ltd’s Sanctions Policy Statement and that Axis Bank, including its subsidiaries and affiliates (the “Group”), is firmly
committed to complying with all applicable sanct ions laws (as imposed by UN, US, UK, EU or any other Government and/or Regulatory authorit ies) that are
legally binding upon the Group and its businesses.
16. I / We are further aware that Axis Bank Ltd may be unable to process any transact ions that involves or have linkages / reference to any sanct ioned
countries*/territories*/parties including for cases where transhipment is involved.
17. I / We conf irm that shipment and / or transhipment of goods covered under this transact ion shall not involve any sanct ioned countries / territories / parties.
18. Any statutory levy including dut ies or taxes payable as a result of the use of the Card shall be Cardholder’s responsibility and if imposed on / recovered / sought
to be recovered from Axis Bank (either directly or indirectly), such statutory levy shall be deducted from the Axis Bank Multi-currency Forex Card Balance and
/ or recovered directly from the card funder and/ or from any accounts (including joint accounts) maintained by the Cardholder with Axis Bank or its group companies.
a). If aggregate foreign currency purchases in any form during the financial year exceeds INR 7 Lakhs and where the foreign currency purchase was made under
LRS by the card funder, card funder shall bear the applicable Tax Collected At Source (TCS) at the rate of 5% under applicable laws on the amount exceeding INR 7 Lakhs
b). In cases where the amount loaded or reloaded for the purpose of pursuing educat ion abroad through an educat ion loan obtained from a financial inst itut ion,
in such a case card funder shall bear the applicable TCS at the rate of 0.5% under applicable laws on the amount exceeding INR 7 Lakhs. For the sake of clarity,
Financial inst itut ion shall have the same meaning as def ined u/s 80E of the Act
*Sanct ioned Countries and Territories include Cuba, Iran, Syria, North Korea (also known as Democrat ic People’s Republic of Korea), Crimea and Sevastopol
(also known as Crimean Autonomous Republic) and Sectorial Sanct ioned Countries and Territories include Russia and Venezuela. The list of sanctioned countries and
territories change from time to time, hence visit https://www.axisbank.com/sanction-policy-statement for updated list of sanctioned countries and territories.
19. I/we hereby agree and acknowledge that Ecommerce and Contactless transactions on the Forex card when issued will be blocked. The same can be activated
through Internet Banking, Mobile Banking, Axis Prepaid Card Portal or Axis bank branch.
20. I/we also acknowledge that channels like ATM, POS transactions at merchant outlets, Online or contactless and their limits can be enabled or disabled/ increased
or decreased through Internet Banking, Mobile Banking, Axis Prepaid Card Portal or Axis bank branch.
21. I/we agree and acknowledge that in accordance with Finance Act, 2021, sections 206AB and 206CCA in the Income-tax Act 1961, I/we will be levied higher rate
of TCS (wherever applicable) if found to be a Specified Person as per Income Tax Department records.
Signature of applicant *

Name ___________________________________________________________________________
Signature
*Where the applicant is minor, the application should be countersigned by minor’s natural guardian

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 Please sign this authorizat ion*
I am a holder of an Axis Forex Card issued to me by Axis Bank and declare that any informat ion provided in this Form is true and correct and that I am an Indian cit izen
and that I am eligible to hold an internat ionally valid Forex Card. I agree and accept that Axis Bank is ent itled in its absolute discret ion to accept or reject this Form
without assigning any reason whatsoever. It is my responsibility to adhere to the Terms and Condit ions as applicable to Axis Bank Forex Card and read and understand
the same. I agree and confirm to be bound by the Terms and Condit ions governing the Axis Bank Forex Card, as may be in force from t ime to t ime and the use of the Card
shall be deemed to be acceptable of those Terms and Condit ions. I am aware that by agreeing to the Terms and Conditions governing the Axis Forex Card I am estopped
from taking a plea subsequently that I have not been aware of the same. I authorize Axis Bank and / or its associates to verify any informat ion or otherwize at my of f ice
/ residence or to contact me, my Employer Banker / Credit Bureau RBI or any other source to obtain or provide any informat ion that may be required for conf irming
membership requirements or maintaining my account in good standing. I agree to an ongoing conf irmat ion for use of my name, address, e-mail and mobile number for
market ing / merchandising offers between Axis Bank and other companies. I understand and acknowledge that local laws and Reserve Bank of India rules and regulat ions
lay down norms and limits for the purchase and use of Foreign Exchange. I undertake that the usage of Axis Bank Forex Card by me will be in accordance with Exchange
Control Regulat ion of the Reserve Bank of India and the applicable laws in force from time to time, in particular and without informat ion, the Foreign Exchange
Management Act, 1999. In the event of any failure on my part to comply with the applicable laws, rules and regulat ions or in the event of any informat ion supplied by me
being incorrect and inaccurate, I agree that I will be solely liable for any / all penalt ies and / or action under the local laws and / or regulations as may be in force, governing
the purchase and use of the Axis Bank Forex Card and shall indemnify Axis Bank for any losses or damages caused to the Bank. I also understand that a Service Tax is
applicable on all fees, interest and other charges as per the Government of India regulat ions and agree to pay the same. I agree and acknowledge that Axis Bank will act
on requests made by me or any other person(s) (Cardholder’s relat ive) other than me act ing on my behalf and claiming to represent me for reloading in / seeking refund
from the Axis Bank Forex Card issued to me. In case of any person other than me act ing on my behalf representing me for reloading in / seeking refund from the
Axis Bank Forex Card issued to me, I shall not contest any such requests made for reloading in / seeking refund from the Axis Bank Forex Card issued to me. The Forex
card will be funded post all documents are received and compliance verif icat ion is completed successfully. I hereby agree that I will be solely liable for all the acts done
or requests made by me or any other person act ing on my behalf with respect to reloading and seeking refund from the Axis Bank Forex Card issued to me shall indemnify
Axis Bank for any / all the losses or damages caused to Axis Bank due to act ing on all such requests made by me or in my behalf by any other person.

Signature
Place _____________________________________________________________________________________

For Branch use only (Mandatory)

This is to cert ify that the remit tance is not being made by / to ineligible ent ities and that the remit tances is in conformity with the instruct ions issued by Reserve
Bank from t ime to t ime under Scheme. For NTB Customer, OSV of KYC documents is done by Branch / Operat ion Head & "AML due diligence is done for high
cash value transact ions" done for high value transact ions.
I cert ify that I have verif ied the Customer's Signature as per Bank records and retained the originals of all the scanned documents and forms submit ted by the
remit ter for the above transact ions.

Forex Card # Account Reference #

Branch SOL* Branch Name*

Employee ID* Name of issuing Authority*

If applicable at tach:
Minor Declarat ion or Sole Proprietorship Declarat ion
Employee's Signature Stamp and Seal
Date Place _________________________________________________________

Cert ificate by the Authorized Dealer

This is to cert ify that the remit tance is not being made by / to ineligible ent it ies and that the remit tance is in conformity with the instruct ions issued by
the Reserve Bank from t ime to t ime under the Scheme. For NTB Customer, 'OSV of KYC docs is done by Branch / Operat ion Head' & 'AML due diligence is
done for high Cash Value Transact ions' We have ascertained and verif ied the source of funds for the applicant and found in order.

Name _____________________________________________________________________ Designat ion of the Authorized Of f icial ________________________________________________________________________

Place ________________________________ Stamp ________________________________ Signature & SSN ___________________________________________ Date __________________________________________

I certify that I have verif ied the Customer's signature as per Bank records and retained the originals of all the scanned documents and forms submit ted
by the remit ter for the above transact ion.

Referral Agent’s Use Only

1. We request Axis Bank to send outward remit tance(s) / issue Demand Draft(s) / Forex Card (s) on behalf of our customer (Applicant) as per details submit ted in this Applicat ion
Form. This Applicant is referred to Axis Bank basis the Referral Agreement-cum-Indemnity executed between Axis Bank and us dated __________. All the Terms and Condit ions
stated in the said Referral Agreement-cum-Indemnity shall be applicable to this remit tance / purchase transact ion. The Applicant shall submit all the required KYC and other
necessary documents as required by Axis Bank. The funds for the said remit tance / purchase transact ion(s) shall be arranged directly by the Applicant to Axis Bank.

2. We confirm and declare that the facts stated above are true and correct and that we are aware that Axis Bank has solely relied on the above statement for undertaking the
remit tance / purchase transact ion(s) as requested by the Applicant and that Axis Bank is not under obligat ion to verify the veracity of the statements as above and Axis
Bank shall not be held liable for any discrepancies or erroneous statements as contained herein and we further conf irm that Axis Bank shall stand indemnif ied at all t imes
for any loss incurred by Axis Bank on account of any misrepresentat ion by us or by the Applicant.

Agent Name Referral Code Signature & Stamp

For CPU use only

Received on Modif ied on:

Verif ied by ___________________________________________ Authorized by___________________________________________ Addit ional Remarks___________________________________________