WS ID Signature Date Officer Approver Payment Instruction Form

To: The Hongkong and Shanghai Banking Corporation Limited
Address: _________________________________________________________________
Reference No:___________________________
Debit Account Details
HSBC A/C No*.: ______-_________-_____
*Payment Currency :
Clear Form
Customer Name*: ____________________________________________________________
Contact No:________________________
Date ___________
Payment Instruction Form
Incorporated in Hong Kong with limited liability
* Mandatory Field
Charge * : From Same Account
HSBC A/C No*.: ______-_________-______
Other (Specify) _______________
Amount in Payment Currency*: ______________________________ OR
Amount in Debit A/C Currency: _____________________________
Amount in Words:* __________________________________________________________
Payment Type*
Cashier’s Order
Local Demand Draft
Overseas Demand Draft
Local TT
Overseas TT
Bangladesh Bank Cheque
A/C Transfer within HSBC
Share (Mandatory for Overseas TT)
Overseas TT Value Date*: ___________ (dd/mm/yyyy ) (Mandatory for Overseas TT)
Overseas TT Charge:
Beneficiary Details
A/C No/ IBAN NO*:________________________ Bank Code/SWIFT:___________________
Beneficiary Address* : _________________________________________________________
(Mandatory for ORTT) ______________________________________________________________
Bank Name: _____________________________________________________________
Telegraphic Transfers (TT) and Demand Drafts (DD)
1. In absence of any specific instructions to the contrary the TT/DD will be effected In the currency of the country In which
payment is to be made.
2. All the charges for Overseas TT will be as per customer instruction. If no instruction are given, charge will be shared by remitter
bank and Beneficiary bank (Charge type SHA).
3. The Bank reserves the right to draw this TT/DD on a different place form that specified by the remitter if operational
circumstances so require.
4. TT is to be dispatched entirely at the remitter's own risk and bank will not be responsible for non execution due to system
5. For a DD the Bank will not be responsible for mail service failure if it is dispatched on behalf of the remitter.
6. Where the Bank is unable to provide a firm exchange rate quotation, the Bank shall effect the remittance on the basis of a
provisional exchange rate which shall be subject to adjustment when the actual exchange rate is ascertained. Any
difference between the provisional rate and actual rate shall be debited/credited (as the case may be) to the Applicant's
7. The Bank is at liberty to send the TT either literally or in cipher and the Bank accepts no responsibility for any loss, delay, error,
omission or mutilation, which may occur in the transmission of any message or for its misinterpretation when received.
8. Applications received after Bangladesh Bank prescribed transaction hours will not be processed on same day and shall be
processed on the next business day.
9. Credit to beneficiary are subject to cut-off time of transaction processing and business days related to the geographical location
of destination.
Payment Screening
The Bank (HSBC in Bangladesh) and other members of the HSBC Group)are required to act in accordance with the laws,
regulations applicable in the jurisdictions in which they operate, relating to, amongst other things, the prevention of money
laundering, terrorist financing and the provision of financial and other services to any persons or entities which may by subject
to sanctions. The Bank may take, and may instruct (or be instructed by) any other member of the HSBC Group to take any
action which it or such other member, in its sole and absolute discretion considers appropriate to take in accordance with all
such laws, and regulations.
Such action may include but is not limited to: the interception and investigation of any payment message and other
information or communications sent to or by the account holder or on the account holder's behalf via the systems of the Bank
or any other member of the HSBC Group; and making further enquiries as to whether a name which might refer to a
sanctioned person or entity actually refers to that person or entity.
The Bank may not be permitted to handle transactions, which fall under descriptions set out by such sanctions and
programmes. Any transactions involving sanctioned countries or entities or Specially Designated Nationals (SDNs) may not
be carried out or put through by the Bank.
Neither the Bank nor any member of the HSBC Group will be liable for loss (whether direct or consequential and including,
without limitation, loss of profit or interest) or damage suffered by any party arising out of:
Branch Name: ___________________________________________________________
Bank Address : __________________________________________________________
Purpose/Remarks: _________________________________________________________
DD Payable At: __________________________________________________________
any delay or failure by the Bank or any member of the HSBC Group in processing any such payment message or other
information or communications, or in performing any of its duties or other obligations in connection with any accounts or
the provision of any services to the account holder, caused in whole or in part by any steps which the Bank or such
other member, in its sole and absolute discretion, considers appropriate to take in accordance with all such laws,
regulations and requests; or
the exercise of any of the Bank's rights under this clause.
In certain circumstances, the action which the Bank may take, may prevent or cause a delay in the processing of certain
information. Therefore, neither the Bank nor any member the HSBC Group warrants that any information on the Bank's
systems relating to any payment messages or other information and communications which are the subject of any action
taken pursuant to this clause is accurate, current or up-to-date at the time it is accessed, whilst such action is being taken.
Received at HSBC __________________________________ Branch
The Bank and the members of HSBC Group shall be held harmless and indemnified from and against all loss, costs, charges,
claims, demands, expenses, or any other liability (including costs of investigations, attorneys' fees, and expenses of
litigations), judgments, fines, penalties, interests, and amounts paid in settlement (each referred to herein as a "cost") arising
out of or in connection with the Bank effecting the TT/DD.
Received By : Name of Authorized Person________________________________________
CO/DD/BBK Cheque : Sent to Customer Address
Sent to Beneficiary Address
CO/DD/BBK Cheque no:
Receiver’s Signature: __________________________________________
S. V.
Customer Signature