International Payments/ S.W.I.F.

T Transfers

Shaded areas are for offical use only*

For Offical Use

Branch name Centre number BPID Date (YYYY-MM-DD)

Applicant’s details

Surname/legal entity name Date of birth (YYYY-MM-DD)

Full name(s)/trading name Gender

Residential status RSA resident Non resident Foreign national temporarily resident in South Africa

Emigrant Immigrant South African resident temporarily abroad

If temporary resident state permit expiry date (YYYY-MM-DD)

Identity/temporary resident/registration/foreign identity number ID country code

Institutional sector Industrial classification

VAT number Tax number

MRN (Movement Reference number for imports) Customs client number

Tax clearance certificate number

Physical address (Complete business physical address for company transfers) Postal address (if same as physical address please tick box)
Street 1 Address 1

Street 2 Address 2

Suburb Suburb

City City

Province Code Province Code

Third party details

Is there a third party involved in this transaction? Yes No

If yes, please complete the form number 00176057 with the third party details.

Only for travel

Passport number Passport expiry date (YYYY-MM-DD)

Passport country Ticket reference number

Destination country Airline

Departure date (YYYY-MM-DD) Border post/place of departure

Return date (YYYY-MM-DD) Other mode of transport

Contact person

Full names Surname

Telephone Fax number

Email address

Account from which money will be charged against

Account Account name Account number

Account type Current Savings Credit card Cash

00192374 2019-05 The Standard Bank of South Africa Limited (Reg. No. 1962/000738/06) An authorised financial services and registered credit provider (NCRCP15). Page 1 of 3
Transaction details (Shaded areas are for offical use only)

Transaction 1 Transaction 2

20 Transaction reference number

23E Instruction code

Related transaction if reversal

32A Currency code

Currency amount

Amount in words

Rand equivalent (R)

Value date (YYYY-MM-DD)

Exchange rate
Cover or Forward Exchange
Contract (FEC) number

57 Beneficiaries bankers account number/

Sort code/BIC

Bank name

Bank address 1

Bank address 2

Beneficiary details
59 Beneficiary customer’s
account number/IBAN
Surname/Legal entity name
Full names

Address 1

Address 2
City State State

Country Zip code Zip code

Country of origin of goods/services/
payments

70 Details of payment
*For information on the balance of payments categories relating to your transactions, please visit your nearest Standard Bank Foreign Exchange outlet
or visit www.standardbank.co.za
Balance of payment (BOP)*

Description if 830 (give details)

71A **Details of charges Our Ben Share Our Ben Share

**Our = All transaction charges are to be paid by the ordering customer.

Ben = All transactions charges are to be paid by the beneficiary customer.
Share = Transaction charges on the sender’s side are to be paid by the ordering customer, transaction charges on the receiver’s side are to be paid
by the beneficiary customer.
Do you want us to send you proof of
payment? Yes No If yes, confirm email address

Destination/SWIFT address

Foreign agent code

Senders correspondent

54A Receivers correspondent

72 Sender or receiver information

Loan (Repayment of loan made to a resident by a non-resident)

Reference Tenor Date (YYYY-MM-DD) or On demand

Interest rate

00192374 2019-05 Page 2 of 3

Single Discretionary Allowance documents dispensation declaration
I hereby declare that the supporting documentary evidence for this transaction as required in terms of the relative section of the South African Reserve
Bank Exchange Control Rulings is not available.
I confirm that I have authorised the Bank to process this transaction under the Single Discretionary Allowance (SDA) documents dispensation and I am
aware that the transaction amount will be deducted from my SDA limit of R1 000 000.00 (one million) per calendar year.

Name Surname

Signature

Subject Description

Prominent Influential Persons (PIPs)

Prominent Influential Persons (PIPs) are individuals entrusted with prominent public functions either domestically or by a foreign country.
Examples are heads of state or heads of governments, important political party officials, military officials or senior executives of state owned corporations.
This term also includes immediate family members and close associates.

Are you a public official in a position of authority? Yes No

Are you related to or associated with a public official in a position of authority? Yes No

What is the nature of the relationship or association? Business partner Close associate Parent

Sibling Son/Daughter Spouse/Partner

Please provide full name and surname of relative or associate

Declaration
I/we, the undersigned ,hereby declare that:
• I/we have read this document and know and understand the contents thereof;
• the information furnished above is in all respects both true and correct;
• the currency applied for will only be used for the specific purpose stated herein;
• the documentation presented in support of this application is in all respects authentic;
• I/we consent to this information being provided to the South African Revenue Service and/or the Financial Intelligence Centre; and
• If this foreign exchange was sold to me/us for travel purposes, I/we declare that I/we will travel within 60 days from the date it was bought.
• I/we have been informed of the limit applicable to the above transaction and confirm that this limit will not be exceeded as a result of the conclusion of this transaction;

Single Discretionary Allowance (SDA) for Residents (Natural persons) who are18 years and above-R1 000 000,00 (One million Rand) per calendar year

Travel allowance for Residents (Natural persons) who are under the age of 18 years R200,000.00 (Two hundred thousand rand) per calendar year

Capital Allowance of R10 000 000,00 (Ten million rand) per calendar year per private individual who is a taxpayer in good standing and is 18 years and older, for
investment purposes abroad

Confirmation
I/we acknowledge that you are not liable for errors, omissions or delays in transmissions arising from circumstances beyond your control. I/we authorise you to set aside funds
to cover all and any amount(s) relating to the transaction(s) by debiting the account(s) shown above with such amount(s) immediately. I/we accept that the transaction(s) may
take up to two working days to be completed and that you will not be held liable for any loss of interest on such amount(s) during this period. Client is responsible to ensure
authenticity of payment details as the Bank cannot be held liable for errors.
I/we confirm that any confidential information about my/our banking details/transactions under your control and possession may/will be used, disclosed and kept by you in
compliance with your obligation under national and international law/standards. Foreign exchange provided may only be used for the purpose for which it was made available.
Any unused foreign exchange will be resold to an authorised dealer within 30 (thirty) days of my/our return to this country or from the date of cancellation of the trip.

Signature
Keep this receipt as proof of foreign currency brought into South Africa if changing surplus South African Rand to
foreign currency on departure from this country. Branch date stamp

Applicant signatory Authorised signatory

Date (YYYY-MM-DD)

For Official Use

FINSURV Authority number If internal date (YYYY-MM-DD) Omnibus facility Yes No

Currency and Exchanges Manual for Authorised Dealers section BOP category

E-Docs

Signature verified Yes No Intials FICA/KYC complete Yes No Intials

Sanctions screening checks Yes No Intials

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