Request for Conversion of IBRD Loan/IDA Non-Concessional Financing
Currency Conversion of Unwithdrawn Amount
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;, specified above and not for speculative purposes; and(e) we are undertaking the Conversion in order to facilitate the prudent debt management as(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 terminationsof the Conversions on the Bank’s website at http://treasury.worldbank.org/.

Currency to be Paid Following Conversion:
Transaction
fees forms must be submitted for each tranche)(Separate request

Please specify if only specific categories under the Withdrawal Schedule of Loan Agreement are to be converted: Refer to Section III.6.2of the Bank Conversion Directive.

Choose one:
Convert the full unwithdrawn amount, orConvert
Convertpercent of the unwithdrawn amountof the unwithdrawn amount subject to the minimum
requirements specified in the Bank Conversion Directive

Change the currency toFor information on the Effective Date of Conversion, please see Section III.4.6 of the Bank Conversion
Directive.Please list any Special Commitments denominated in the new currency which you wish to form part of the Conversion.
Please see Section III.8 of the Bank Conversion Directive.

Please specify if a Designated Account in the new Approved Currency is to be opened:
Please see Section III.9 of the Bank Conversion Directive
Special Instructions:

Request for Conversion

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Currency Conversion of Unwithdrawn Amount
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 Unwithdrawn Amount