Request for Conversion of IBRD Loan/IDA Non-Concessional Financing
Automatic Rate Fixing
Request is based on the General Conditions applicable to the loan agreement and the Bank Directive "Conversion of Financial Termsof IBRD and IDA Loan and Financing Instruments" (the "Bank Conversion Directive"). Capitalized terms have the meaning given to themin 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 suchConversion;(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
Loan Closing Date
Loan Final Maturity Date
Next Interest Payment Date
Loan Currency

Information on the Requested Conversion:(All sub-loans listed below must have identical financial terms and Conversion requirements. Separate request forms mustbe submitted for other sub-loans having different financial terms and Conversion requirements.)
Automatically fix the rates on the following sub-loans:

Automatically fix the Reference Rate only, with the following options:
Choose one:
Either:Automatically fix the Reference Rate of newly disbursed amounts which have accumulated within a:semesteryear
other multiple of semester: Please describe:Or:
Automatically fix the Reference Rate of newly disbursed loan amounts each time the accumulated disbursed amount reachesa threshold ofamount of the outstanding loan balance, subject to the minimum requirements

specified in the Bank Conversion Directive.

Request for convesion

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Automatic rate fixingRequest for Conversion of IBRD Loan/IDA Non-Concessional Financing
Automatic Rate Fixing(Refer to section III.3.4 of the Bank Conversion Directive)

Special Instructions:

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

Authorizations:

Specimen signatures of the authorized representatives of the Borrower / Recipient below must be on file at the Bank before processing of thisrequest may begin. By signing this Request, the Borrower / Recipient acknowledges and agrees that the Conversion shall be effected inaccordance 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:

Telephone:
Facsimile:

Name:
Title:
Address1:
Address2:

Email:

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
E-mail: askloans@worldbank.org

Request for convesion

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Automatic rate fixing