BANK USE ONLY OP

OUTWARD/CROSS BORDER/INTERNATIONAL PAYMENT REQUEST

For any assistance please call the Nedbank Contact Centre on 0860 797 797
1

YOUR (SENDER) DETAILS Date of application

Contact information (ddmmyyyy) 2 0
Sender’s own
reference number

Entity Entity name

line 1

Entity name line

2

Trading name
line 1

Trading name
Tax number
line 2

Company VAT
registration number number

First
Individual
name

Surname

Residential
Gender Male Female Resident Non-resident Tax number
status

ID/Temporary permit Date of birth

/Passport number (ddmmyyyy)

Country where passport

was issued

Complete for entity Physical

and individual address line 1

Physical
address line 2

Physical
address line 3

Suburb City

Post
Province
code

Country

Is the postal the same as Postal

Yes No
the physical address? address line

Suburb City

Post
Province
code

Country

Sender’s First
contact person name

Contact
Surname
number

Email
address line 1

Email
address line 2

Are you/Is the entity the If ‘NO’, complete Is it a joint If more than one account must be debited for settlement
Yes No Yes No
accountholder? Appendix A account? of the payment, complete Appendix C

Nedbank account name

line 1

Nedbank account name Nedbank

line 2 account no

Are you an international head- Is there a third

Yes No If ‘YES’, complete Appendix A Yes No If ‘YES’, complete Appendix B
quartered company (IHC)? party involved?

Initial here

Nedbank Ltd Reg No 1951/000009/06. Authorised financial services and registered credit provider (NCRCP16) Page 1 of 5 Outward|CrossBorder|InternationalPaymentRequest.01Feb19
 Rand Payment value date
32A Payment information
amount . (ddmmyyyy) 2 0
OR Foreign (if the foreign currency equivalent of a rand amount is to be paid,
Currency
amount . provide the rand amount; also indicate the foreign currency to be
used for the payment)
Amount in words line 1

Amount in words line 2

Obtain FEC rate Phone contact FEC already FEC An FEC is a forward exchange
on your behalf person before booked number contract. If more than one FEC is
converting applicable, complete Appendix C
South African Reserve
Bank (SARB) authority Date authority granted
number (if applicable) (ddmmyyyy) 2 0
Name of bank where
authority is held
BENEFICIARY (RECEIVER) DETAILS
Entity Entity name
59
line 1

Entity name
line 2

First
Individual
name

Surname Gender Male Female

Physical
address line 1

Physical
address line 2

Physical
address line 3

Suburb City

Post
Province
code

Country

Account number/International bank account number (IBAN)

Beneficiary bank
57 Name of bank

Name of branch

Physical address

Country SWIFT address

Clearing code type Clearing code

56A Is there an intermediary/correspondent bank for the beneficiary bank (optional for routing payment to beneficiary bank)?
If yes,
Yes No
name of bank

Name of branch

Physical address

Country SWIFT address

Clearing code type Clearing code

70 Full reason for payment

All local and overseas charges All local and overseas charges Local charges borne by remitter and
71
to be borne by beneficiary (BEN) to be borne by remitter (OUR) overseas charges by beneficiary (SHA)

Please complete the account to be debited details if ‘OUR’ or ‘SHA’ as applicable Account to be debited

72 Bank-to-bank information (BANK USE ONLY)

Initial here

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 BALANCE OF PAYMENT (BoP) REPORTING CATEGORIES – OUTWARD PAYMENTS NOTES:
• Specify the relevant BoP categories and additional mandatory information for this transaction
• For outward BoP category codes contact your nearest forex branch or transactional manager or go to:
https://www.nedbank.co.za/content/dam/nedbank/Forms/Application%20Forms/Personal/Forex/BOP_Category_Guide.pdf
• If more than one BoP category is applicable, complete Appendix D

Country of origin (country from which

goods and services originate)

BoP category sub-

code category
Amount .
CCN1 INV/MRN2

Transport
doc no3

Vessel
name 3

Loan Original
ref no4 ref no5
Notes: 1 Client customer number (CCN) is mandatory for BoP categories 100, 101, 102, 103, 2 INV/Movement reference number (MRN) is mandatory for BoP categories 101, 103,
104, 105, 106 and 109 105 and 106
3 Transport document number and vessel name is mandatory for 4 Loan reference number is mandatory for BoP categories 309 (4-7) 106, 801, 802, 803
BoP category 101, 103, 106 and 271/03 and 804
5 An original reference number is mandatory for BoP categories 100, 200, 300, 400,
500, 600, 700 and 800
Is import permit
Import permit declaration Yes No I/we confirm that I/we hold import permit number
required?
if ‘YES’, complete this
section with the import
permit details dated (ddmmyyyy) expiring on (ddmmyyyy)

ACKNOWLEDGEMENT AND INDEMNITY: I/We acknowledge the following:

1. The SARB authorities require that the Sender and the accountholder (if they are separate persons/entities) keeps the related documentary evidence of this transaction available for inspection for a
period of 5 (five years).
2. Any quotation, indication, communication or notification in any form by Nedbank of the exchanges rate is merely indicative of such rate at that point in time and is subject to change without notice
and shall not be binding on Nedbank, unless confirmed by Nedbank in writing. I/We acknowledge and agree further that delays may be experienced during the completion of the transaction due to
regulatory requirements and Nedbank’s internal procedures to comply with any such regulatory requirements.
3. Nedbank shall not be liable in any way whatsoever for errors or delays in transmission, non-arrival as a result of telecommunication errors, misinterpretation on receipt of instructions and/or failure to
identify the stated beneficiary. Nedbank shall not be liable for any loss or damage from whatever cause arising from the aforesaid.
4. I/we acknowledge that there may be delays in the processing of my/our payment instructions from time to time due to currency holidays or any settlement procedures and accordingly I/we hereby
indemnify Nedbank against and hold it harmless from any claim, liability, losses or damages of whatsoever nature that I/we may incur, whether directly or indirectly and howsoever arising, as a
consequence of such delays.
5. Certain payments may, through the operation of international law, the laws and regulations of other jurisdictions, and/or international or governmental practice, whether or not having the force of law,
be prohibited, confiscated, embargoed, withheld or otherwise prevented from being made before such payments have reached the intended recipient(s). Nedbank undertakes to notify me/us if any
payment is so prohibited, confiscated, embargoed, withheld or otherwise prevented from being made as soon as Nedbank becomes aware thereof.
6. Nedbank shall utilise any information that it may receive in relation to this transaction (which may not be limited to information appearing herein), and sh all utilise any mechanism that it deems
appropriate in order to satisfy applicable international legal requirements.
7. Accordingly, I/we indemnify Nedbank against and hold it harmless from any loss of damage whatsoever that I/we may suffer or incur, directly or indirectly as a consequence of any of the aforesaid.
DECLARATION: I/We hereby declare the following:
1. The information furnished above is true and correct in all respects.
2. The currency applied for will be used only for the specific purpose stated;
3. Any documentation required in terms of the SARB Currency and Exchanges Manual for Authorised Dealers and presented in support of this transaction is authentic in all respects;
4. The conclusion of this transaction in itself or in conjunction with such other transactions of this type will not result in the overall limit imposed by the SARB rulings and Regulations being exceeded;
5. I/We am/are aware that the information relating to this transaction will be furnished to SARB, the South African Revenue Service, the Financial Intelligence Centre and the Financial Sector Conduct
Authority and I/we consent thereto, and
6. I/We have read this document and the content hereof is known and understood by me/us.

Signed at (place) on (ddmmyyyy) 2 0

For and behalf of (full company name)

Authorised signature of sender Authorised signature of sender

BANK USE ONLY – FOR USE BY THE AUTHORISED DEALER (AD)

Exchange provided in terms of section of the SARB Currency and Exchanges Manual for Authorised Dealers

Date of authorisation
AD internal authorisation
(ddmmyyyy) 2 0

OR SARB authority number

Date and bank stamp

Date of SARB reply (ddmmyyyy) 2 0 of authorised dealer

Submitted by

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Note that the authorised accountholder’s signature(s) is required at the bottom of the next page for both Appendix A and B

APPENDIX A: ACCOUNTHOLDER AUTHORISATION - Please complete this section if you are not the accountholder and/or you are an IHC
Entity Entity name
line 1

Entity name
line 2

Trading name
line 1

Trading name
line 2

Company VAT number

registration number (mandatory for imports)

Tax number
IHQ number
(mandatory for imports)

First
Individual
name

Surname

Residential
Gender Male Female Resident Non-resident Tax number
status

ID/Temporary permit Date of birth

/Passport number (ddmmyyyy)

Country where passport

was issued

Complete for entity Physical

and individual address line 1

Physical
address line 2

Physical
address line 3

Suburb City

Post
Province
code

Country

Is the postal the same as Postal

Yes No
the physical address? address line

Suburb City

Post
Province
code

Country

APPENDIX B: THIRD PARTY AUTHORISATION - Please complete this section if a third party is involved
Entity Entity name
line 1

Entity name
line 2

Trading name
line 1

Trading name
line 2

Company VAT number

registration number (mandatory for imports)

Tax number
(mandatory for imports)

Initial here

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 First
Individual
name

Surname

Residential
Gender Male Female Resident Non-resident Tax number
status

ID/Temporary permit Date of birth

/Passport number (ddmmyyyy)

Country where passport

was issued

Complete for entity Physical

and individual address line 1

Physical
address line 2

Physical
address line 3

Suburb City

Post
Province
code

Country

Is the postal the same as Postal

Yes No
the physical address? address line

Suburb City

Post
Province
code

Country

Signed at (place) on (ddmmyyyy) 2 0

For and behalf of
(full company name)

Authorised signature Authorised signature

of accountholder of accountholder

Obtain FEC rate Phone contact person

APPENDIX C: MULTIFUNDING - Complete this section if more than one account must be debited or more than one FEC must be used for
on my behalf before converting
settlement of the payment. Note the following abbreviations to be used: Savings (SA), current CA), Client Foreign Currency (CFC), cheque
(CH), General Ledger (GL). Should more than five accounts or FECs be required, please attach additional appendices.

Type of
Account number Currency Amount Existing FEC number booked
account

.
.
.
.
.
APPENDIX D: BALANCE OF PAYMENT (BoP) REPORTING CATEGORIES – OUTWARD PAYMENTS NOTES - Please complete this section if more than one BoP category is involved
BoP category Sub-
code category
Amount .
BoP category Sub-
code category
Amount .
BoP category Sub-
code category
Amount .
BoP category Sub-
code category
Amount .
BoP category Sub-
code category
Amount .

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