Dutch-Bangia Bank Limited

To receive money

Complete the for~ and present with valid 1.0.

For WesternUnion CardSMholders,
pleasefill in you~card.number.
Operator
number

, Check Payout
number Amount
Amount / Currency sent by Sender

1 1

Originating city / country

Expected payout
city/country

City, state/ province, country money sent from

MoneyTransfer Control No.
(if available)

CERTAIN TERMS AND CONDITIONS GOVERNING THE MONEY TRANSFER SERVICE YOU HAVE SELECTED ARE SET FORTH ON THE BACK OF THIS FORM. BY
SIGNING THIS FORM, YOU ARE AGREEING TO THOSE TERMS AND CONDITIONS. IN ADDITION TO THE TRANSFER FEE, WESTERN UNION AND ITS AGENTS ALSO
MAKE MONEY FROM THE EXCHANGE OF CURRENCIES. 'PLEASE SEE IryiPORTANT INFORMATION ~EGARDING CURRENCY EXCHANGE AND OTHER LEGAL
RESTRICTIONS THAT MAY DELAY THE TRANSACTION SET FORTH ON THE BACK OF THIS FORM. UNLESS YOU HAVE CHOSEN TO BE PAID A CURRENCY
DIFFERENT FROM THE ONE DESIGNATED BY YOUR SENDER, THE CURRENCY TO BE PAID AND THE EXCHANGE RATE FOR YOUR TRANSACTION ARE
TYPICALLY DETERMINED AT THE TIME THE TRANSACTION WAS SENT. .

WUIfCountry/ENG/Agent number/August 200S/or and date of change)

Copyright@ 2008 Western Union Holdings, Inc, All Rights Reserved.
 Dutch-Bangia Bank limited
To receive money

Complete the form and present with valid I.D.

For Western Union CardsMholders, please fill in your card number.
Operator
number

Check Payout
number Amount
Amount I Currency sent by Sender

1 1

Originating city / country

Expected payout
city/country

City, state/ province, country money sent from

Money Transfer Control No.
(if available)

CERTAIN TERMS AND CONDITIONS GOVERNING THE MONEY TRANSFER SERVICE YOU HAVE SELECTED ARE SET FORTH ON THE BACK OF THIS FORM. BY
SIGNING THIS FORM, YOU ARE AGREEING TO THOSE TERMS AND CONDITIONS. IN ADDITION TO THE TRANSFER FEE, WESTERN UNION AND ITS AGENTS ALSO
MAKE MONEY FROM THE EXCHANGE OF CURRENCIES. 'PLEASE SEE IMPORTANT INFORMATION REGARDING CURRENCY EXCHANGE AND OTHER LEGAL
RESTRICTIONS THAT MAY DELAY THE TRANSACTION SET FORTH ON THE BACK OF THIS FORM. UNLESS YOU HAVE CHOSEN TO BE PAID A CURRENCY
DIFFERENT FROM THE ONE DESIGNATED BY YOUR SENDER, THE CURRENCY TO BE PAID AND THE EXCHANGE RATE FOR YOUR TRANSACTION ARE
TYPICALLY DETERMINED AT THE TIME THE TRANSACTION WAS SENT. .

WUIICountry/ENGfAgent number/August 2008/or and date of change)

Copyright@ 2008 Western Union Holdings, Inc, All Rights Reserved.