Form
[See rules 4(4) or 5(4) and 8]
(The form shall be accompanied by copy of the memorandum of contravention(s) issued, if any)
1. Name of the applicant:
(in block letters)
2. Details of the applicant:
(a) Full address:
(b) Phone No:
(c) E-mail ID:
(if the applicant is a person other than an individual, also provide name, address, phone no., email ID and
designation of the authorised representative of the applicant)
(d) Income Tax PAN:
(e) ECS mandate:
(i) Name of the Party (Beneficiary) -
(ii) PAN -
(iii) Particulars of the Bank Account
A. Name of the Bank -
B. Name of the Branch -
Address:
Telephone No: -
C. Type of Account - SAVINGS CURRENT
D. Account No.: - (As appearing on the cheque book issued by the Bank)
E. The 9 Digit MICR Code Number: - (As appearing on the cheque book issued by the Bank)
F. IFSC Code - (As appearing on the cheque book issued by the Bank)
(iv) Checklist for Attachments (kindly tick):
Photocopy of PAN Card
Photocopy of a cancelled blank cheque
(v) I/We hereby declare that the particulars given above are correct and complete. If the transaction is delayed
or not effected at all for reasons of incomplete or incorrect information, I/We would not hold the user
institution responsible.
Date: Signature of the Authorised Signatory
Place: (Name of the Authorised Signatory)
Official Stamp
(f) Goods and Services Tax Identification Number
3. Whether the applicant is resident in India or resident outside India (please refer to section 2(v) of the Act):
4. Whether any notice has been issued under rule 4 of Foreign Exchange Management (Adjudication Proceedings and
Appeal) Rules, 2000: Yes/ No
If yes, then furnish the following details:
(a) Name of the adjudicating authority, if any:
(b) Date of issue of notice (attach a copy of the notice):
(c) Whether the notice mentions that the contravention attracts the provisions contained in section 37A, or clause
(a) of section 3 of the Act? Yes/No
(d) Whether an adjudication order has already been passed by the adjudicating authority?
Yes/No
5. Specific details of the contravention (according to sub-section (1) of section 13 of the Act):
(a) Act:
(b) Rules:
(c) Regulations:
(d) Notifications:
(e) Order issued in exercise of the powers under the Act:
(f) Condition subject to which an authorisation was issued by the Reserve Bank:
6. Whether a compounding order had been passed against an application submitted previously by the applicant for
compounding under these rules? Yes/ No
If yes, kindly furnish the following details about the previous compounding order:
(a) Date of application for compounding:
(b) Contravention(s) sought to be compounded:
(c) Date of compounding order:
(d) Date of certificate issued by Reserve Bank of India on payment of amount imposed:
7. Brief facts of the case:
8. Details of fee for application of compounding:
9. Undertaking on Directorate of Enforcement investigation:
I/We further undertake to immediately inform in writing, the compounding authority prescribed at rule 4, if any
investigation proceedings are initiated by the Directorate of Enforcement against me/us or the adjudication order is
passed by the adjudicating authority at any time hereafter, but on or before the date of issuance of the compounding
order in respect of the compounding application filed by me/us.
10. Any other information relevant to the case:
I/We declare that the particulars given above are true and correct to the best of my/our knowledge and belief and that
I/we am/are willing to accept any direction/order of the compounding authority in connection with compounding of
my/our case.
Date: (Signature of the applicant)
