Request for Conversion of IBRD Loan/IDA Non-Concessional Financing
Currency Conversion of Outstanding Loan Amounts
Request is based on the General Conditions applicable to the loan agreement and the Bank Directive "Conversion ofFinancial Terms of IBRD and IDA Loan and Financing Instruments" (the "Bank Conversion Directive"). Capitalized terms
have the meaning given to them in the loan agreement, General Conditions or the Bank Conversion Directive, as applicable.

Borrower / Recipient's Explanatory Statement for the Conversion Request:
The Borrower / Recipient's Conversion selection, as requested, and the reasons for this selection, are as follows:

We represent that:(a) we have made our own independent decision to request this Conversion;(b) we are not relying on any communication or confirmation from the Bank as a recommendation to request such Conversion;(c) unless expressly agreed with the Bank by separate agreement, the Bank is not acting as a fiduciary for, or an advisor to, us in respect of such Conversion;(d) we are capable of evaluating and understanding, and understand and accept the terms, conditions and risks of such Conversion, and we are also capable ofassuming, and assume, the financial risks of such Conversion;, s specified above and not for speculative purposes; and(e) we are undertaking the Conversion in order to facilitate the prudent debt management a(f) our representative signing this Request is authorized to do so.

Information on the Existing Loan to be Converted:
Financier (Indicate IBRD or IDA)
Loan Number
Loan/Project Name
Loan Signing Date
Loan Closing Date
Loan Final Maturity Date
Next Interest Payment Date
Loan Currency

Transaction fees:
Transaction
fees The Bank publishes the transaction fees in respect of the Conversions and early terminations ofTransaction fees
the Conversions on the Bank’s website at http://treasury.worldbank.org/.

Information on the Requested Conversion:
Loan amount to be converted:
Choose one:
Convert the full outstanding loan balance
ConvertConvertpercent of the outstanding loan balanceof the outstanding loan balance subject to the minimum requirements
specified in the conversion directive

Convert these particular tranches of the loan:(All tranches listed below must have identical financial terms and Conversion requirements. Separate request

forms must be submitted for other tranches having different financial terms and Conversion requirements.)(tranche numbers)

Choose one:
Convert the full outstanding amount of each tranche above
Convert
Request for Conversion

percent of the outstanding amount of each tranche above
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Currency Conversion of Outstanding Loan Amounts

Request for Conversion of IBRD Loan/IDA Non-Concessional Financing
Currency Conversion of Outstanding Loan Amounts
Conversion Date:

Proposed date that the Conversion will take effect(For guidance in selecting this date, please refer to Section III.4.6 of the Bank Conversion Directive)
Choose one:
Next applicable interest payment date
OtherFinal maturity of the Conversion:
Choose one:
Convert to the final maturity date of the loan or tranches, if market permits
Convert only up to and including this date:

final maturity date of Conversion *(must coincide with a loan payment date)*** Please see paragraph III.6.3 of the Bank Conversion Directive.
For Local Currency Conversions only:
Local Currency Conversions on non-deliverable terms (attach the NDS Annex)

Currency and Interest Rate to Be Paid Following Conversion:
toChange the currency fromFor loans with a fixed spread or a Fixed Rate:
Choose one:
Fixed rate of interest
Variable rate of interest
For loans with a variable spread:
Choose one:
Fixed Reference Rate + variable spread
Variable Reference Rate + variable spread
Optional: Conditional Requests

Execute transactions related to this Conversion request only if: (choose all that apply)
The fixed interest rate or Fixed Reference Rate to be paid excluding any applicable waiver and including
any applicable transaction fee is less than or equal toFor a Conversion from a Fixed Rate or from a Fixed Reference Rate, the spread over Reference Rate tobe paid in a floating rate is less than or equal tobasis points*.

*The above cap will apply without taking into account any applicable interest waiver, but will include applicable transaction fees. For loans
with a variable spread, the above spread will mean the component of the spread to the Reference Rate to be paid by the Bank under theapplicable Market Transaction.

Special Instructions:

Request for Conversion

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Currency Conversion of Outstanding Loan Amounts

Request for Conversion of IBRD Loan/IDA Non-Concessional Financing
Currency Conversion of Outstanding Loan AmountsAuthorizations:
Specimen signatures of the authorized representatives of the Borrower / Recipient below must be on file at the Bank
before processing of this request may begin. By signing this Request, the Borrower / Recipient acknowledges andagrees that the Conversion shall be effected in accordance with the provisions of the Bank Conversion Directive
Name of Borrower / Recipient
By Authorized Representative
Name:

Telephone:

Title:

Facsimile:

Date:

Email:

Signature

Contact Information for Transaction Confirmation:
Name:

Telephone:

Title:

Facsimile:

Date:

Email:

Address1:

Address2:

This completed form and any related correspondence should be addressed to:
Attn: WFA Trust Fund and Loans Department
International Bank for Reconstruction and Development / International Development Association1818 H Street, N.W.
Washington, D.C. 20433, USA

Request for Conversion

Email: askloans@worldbank.org

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Currency Conversion of Outstanding Loan Amounts