Form C

ChapterB I Para2 MF (sx)- 15 FORM 'C' Declaration for remittance received from foreign country of amount equivalent to US $ 2000/- and above APP.s I S l/VVe do hereby declare that l/we have received remittance of D'5oooo #yTlrou*nd (Amount and Currency in figures and in words) to be remitted by on account of (Name and address of remitting bank) the purpose of (Name and address of the remitter) fK €anyo rye,0q Yrielni Nationality - (Name of nKen It(Lrr7 -t2Ng Date Address aPPlicant Form'C'lnward Remittance of Tk. equivalent to US$ 2000 and above. sigffii & stamp of the Month Country making Payment Purpose Amount in (State Curency) Coded by Purpose of remittance We hereby certify that we are satisfied as to the identity of the applicant evidence which satisfies us as to the bonafides of ttre declaration made on this form. ra Signature and Stamp of the Autliorised Dealer Contd. P2. Date remitied or Chec*ed by