Request for Conversion of IBRD Loan/IDA Non-Concessional Financing
Automatic Conversion to Local Currency

Request is based on the General Conditions applicable to the loan agreement and the Bank Directive"Conversion of Financial Terms of IBRD and IDA Loan and Financing Instruments" (the "Bank ConversionDirective"). Capitalized terms have the meaning given to them in the loan agreement, General Conditions or theBank 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
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 must be submitted for other sub-loans having different financial terms and Conversion
requirements.)(sub-loans)

Transaction fees

Transaction fees

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

Request for conversion

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Automatic conversion to local currencyRequest for Conversion of IBRD Loan/IDA Non-Concessional Financing
Automatic Conversion to Local Currency

Currency and Interest Rate to Be Paid Following Conversion:
Automatically change the currency fromtoFor 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 + any spread in the local currency + residual variable spread
Variable Reference Rate + variable spread(Refer to Section III.3.2 of the Bank Conversion Directive)(Refer to the Annex to this Conversion Request for additional terms)
Special Instructions:

Request for conversion

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Automatic conversion to local currencyRequest for Conversion of IBRD Loan/IDA Non-Concessional Financing
Automatic Conversion to Local Currency
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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Currency Conversion of Outstanding Loan Amounts