FORM - Rule 4 or 5 - Foreign Exchange (Compounding Proceedings) Rules 2000.

(To be filed in duplicate and shall be accompanied by certified copy of the Memorandum issued) 1. Name of the applicant: (In block letters) 2. Full address of the applicant: 3. Whether the applicant is resident in India or resident outside India [Please refer to section 2(v) of the Act]: 4. Name of the Adjudicating Authority before whom the case is pending: 5. Nature of the contravention (according to sub-section (1) of section 13 : 6. Brief facts of the case: 7. Details of fee for application of compounding : 8. 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. DATED (SIGNATURE OF APPLICANT)