Form-C

See Chapter 5 Para 10 FORM-C DECLARATION FOR REMITTANCE RECEIVED FROM FOREIGN COUNTRY OF AMOUNT EQUIVALENT TO US S 20,000/- OR EQUIVALENT I/We do hereby declare that I/We have received remittance of _______________________________________ (Amount and Currency in figures and in words) ________________________________________________________________________________remitted or To be remitted by __________________________ on account of ___________________________________ (Name and address of remitting bank) (Name and address of remitter) (Purpose of remittance) Nationality : Japanese (Passport No.: TM1409071 ) Date ……………………. Address : Signature and Stamp of the applicant Form C: Inward Remittance exceeding USD 20,000/- (Twenty Thousand) or equivalent. Month Country of ordering Customers Purpose Amount in (State Currency) Coded by Checked by Purpose of remittance _______________________________________________________________ We hereby certify that we are satisfied as to the identity of the applicant and that we have seen documentary evidence which satisfies us as to the bonafides of the declaration made on this form. Date . Signature and Stamp of the Authorized Dealer Contd. P/2 APP. 5 10 _____________________________ for the purpose of _______________________________________ (Name of Applicant) Mr. Hisaya Takahara √ 6-22-4, Nakano, Nakano-ku,Tokyo, Japan . Page-2 Note: Full details must be given for all remittances which are of capital nature. In the case of amounts for investment in Bangladesh in shares or business, the reasons why the investment is required must be clearly indicated. In the case of the remittance of the sale proceeds of securities the name of the true owner of the securities must be given and also the approximate date of purchase. Inward ID Outward Reference AD Code Ref. Year AD Code Ref. Year (Space for use by the Bangladesh Bank) BANGLADESH BANK Foreign Exchange Policy Department Assistant Director Dated................................. APP. 5 10 See Chapter 5 Para 10