My bank has asked me to fill an Annexure-E form. What details should I fill in under the remitting bank field?

My bank has asked me to fill an Annexure-E form. What details should I fill in under the remitting bank field?

The details of the remitting bank are as follows:

Name of the bank from where remitted: J P Morgan Chase Bank

Name of the branch of the bank from where remitted: J P Morgan Chase Bank, 1111 Polaris Pkwy, Columbus, Ohio