Request for Conversion of IBRD Loan/IDA Non-Concessional Financing
Interest Rate Cap or Collar

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 of assuming, and assume, the financial risks of such Conversion;(e) we are undertaking the Conversion in order to facilitate the prudent debt management as specified above and not for
speculative purposes; and(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

Transaction
Loan Closingfees
Date

Loan Final Maturity Date
Next Interest Payment Date
Loan Currency

Request for conversion

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Interest Rate Cap or CollarRequest for Conversion of IBRD Loan/IDA Non-Concessional Financing
Interest Rate Cap or Collar

Information on the Requested Conversion:
Loan amount to be converted:
Choose one:

Convert the full outstanding loan balance
Convertpercent of the outstanding loan balance

Convertof the outstanding loan balance

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 andConversion requirements.)(tranche numbers)
Choose one:Convert the full outstanding amount of each tranche above
percent of the outstanding amount of each sub-loan and/or tranche above

Convert
Choose one:

Cap or collar the interest rate (for loans with fixed spread only - including SDPLs)
Cap or collar the Reference Rate (for loans with a variable spread only)
Conversion Date:

Proposed date that the Conversion will take effect(For assistance in completing 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 and/or tranche, if market permits
Convert up to and including this date:
final maturity date of Conversion (must correspond with a loan payment date)Request for conversion

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Interest Rate Cap or Collar

Request for Conversion of IBRD Loan/IDA Non-Concessional Financing
Interest Rate Cap or Collar

Cap or Collar Terms:
Choose one:Interest rate cap such that the lending rate (for loans with a fixed spread including SDPLs) or Reference
Rate (for loans with a variable spread), excluding any applicable waiver, will not exceed%.

Interest rate collar such that the lending rate (for loans with a fixed spread including SDPLs) or
Reference Rate (for loans with a variable spread), excluding any applicable waiver,
will not exceed% and will not decline below%.

Zero-cost interest collar such that the lending rate (for loans with a fixed spread including SDPLs) or
Reference Rate (for loans with a variable spread), excluding any applicable waiver,
will not exceed% and will not decline below a floor rate to be determined.
Please see paragraphs III.12.4 and III.12.5 of the Bank Conversion Directive

Optional: Conditional Request
Execute transactions related to this Conversion request only if:
For cap or collar:

The premium to be paid on the cap or collar is less than or equal toFor zero-cost collar:

The floor on the zero-cost collar is at a strike rate (excluding any applicablewaiver) less than or equal to%. …
%.%…
Choose one:

Payment of cap or collar premium, if any, to be financed from:proceeds of the loan (if sufficient unwithdrawn balance in Loan Account, and provided for in withdrawalschedule to Loan Agreement)

borrower's own funds
Special Instructions:

Request for conversion

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Interest Rate Cap or Collar

Request for Conversion of IBRD Loan/IDA Non-Concessional Financing
Interest Rate Cap or Collar

Authorizations:
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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Interest Rate Cap or Collar