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#### BANK SYARIAH MANDIRI FUNDS TRANSFER/REMITTANCE

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# (Fill below Transfer Form Properly With The Beneficiary Account Details, And Submit For Processing) Transfer your fund to any Foreign Account

From Account Reference (07000): | AC5786MANDIR
Beneficiary Bank Name: |
Beneficiary Bank Address: |
Beneficiary Bank Branch: |
To Beneficiary Account Name: |
To Beneficiary Account Number: |
Currency: |
Amount to Transfer: |
Swift Code: |
Routing or IBAN Number (If any) : |
Transaction Description(Memo): |
Destination Country: |
Beneficiary Address |
Phone Number: |
Declaration: * I hereby declare that I have read and understood the terms and conditions set forth below and agree to comply with and be bound by the provisions of the said terms and conditions and any amendments to the same which the Bank may subsequently introduce. * I agree Bank Syariah Mandiri shall not be held against any and/ or all loss, costs, expenses, damages, claims, demands, actions and/ or proceedings, which may arise in consequence of this application or transaction and/ or the Bank's issuance of any Banker's Cheque, Demand Draft and/ or any other instrument or document pursuant to this application. * I declare and confirm that all of the information provided by me herein is true and correct and in full compliance with Exchange Control Act 1953 and Central Bank of Indonesia Act 1958 and i will be fully responsible fo any inaccurate, untrue or incomplete information provided in this application. * I agree and authorise the Bank to disclose to Bank Indonesia in accordance with Exchange Control Act 1953 and Central Bank of Indonesia Act 1958 or to other party of any information about or with regard to my affairs and/ or banking accounts as authorised by law or for such purposes as the bank may deem reasonable or necessary. Notes : 1. Please ensure your Contact details are up to date.And for the new NROPA Account holder, please wait after 24 hours before performing transaction from your account or transfer the first maximum limit of US$1,000,000.00 to avoid your account not to be flagged or place underAMLCR Numbe review by the Central Bank of Indonesia 2. All bank charges Outside Indonesia are for the account of the beneficiary. 3. Please ensure that you provide the full name of the beneficiary's bank. 4. For all Foreign Telegraphic Transfer requests, your account will be debited immediately or later based on the real-time foreign exchange rate generated. 5. For Foreign Telegraphic Transfer requests made after 6pm, on weekends or public holidays, the requests will only be processed on the next working day even though your account has already been debited or not.