FREE TRADE SAMPLE

SAMPLE OF BANK CERTIFICATE FOR FREE TRADE SAMPLE

(On the Bank's letterhead)

Dated: ________________

To,

____________________

Subject: Certificate of Free Trade Sample

We certify that to the best of our knowledge and belief, the Free Trade Sample
shipment being exported (details of which are given below) does not involve any
transactions in foreign exchange as informed by the clients.

Name & Address of Shipper:

Name & Address of Consignee:

Description with clear model/serial/part number:

Invoice number and Date:

Value of Goods as per Invoice:

Kindly allow the export of the above detailed goods on Repair & Return basis on
completion of necessary customs and legal formalities.

Thank you,
For, (Bank's Name)

Authorized Signatory
 INVOICE
EXPORTER Invoice No. & Date Exporter Ref.
SI/124/06/07 DATED 13.03.07
Buyer's Order No. & Date

Buyer ( if other than consignee )

CONSIGNEE

Country of origin of goods Country of final destination

Terms of Delivery & payment

Pre-Carriage by Place of Receipt by pre-carrier CIF / C&F / FOB

Vessel / Flight No. Port of Loading ADVANCEPAYMENT RECEIVED FOR GOODS

Payment Terms:
Port of Discharge Final Destination DP / DA / AP /

Marks & Numbers. No. & kind of Description of Goods Quantity Rate Amount
Container No. KGS

Amount chargeable : TOTAL

( in words / currency )

Declaration:
We declaration that invoice shows the actual price of goods Signature / Date / Co stamp.
described and that all particularss are true & correct.
 PACKING LIST
Exporter Invoice No. & Date Exporter Ref.

Buyer's Order No. & Date

Other reference(s)

Buyer ( if other than consignee )

Consignee

Country of origin of goods Country of final destination

Handling information if any:

Pre-Carriage by Place of Receipt by pre-carrier

Vessel / Flight No. Port of Loading

NA
Port of Discharge Final Destination Net weight: Gross weight :

Marks & Numbers. No. & kind of Description of Goods Quantity Remarks
Container No. Packages

Carton No.
Box No. ** L X B X H cms3 / 6000 =
L ( cms ) X B ( cms ) X H ( cms )
1)
2) Volumetric weight: Kgs
3)
4)
5) Actual weight: Kgs
6)
7) Total Net weight Kgs
8)
9) Total Gross weight Kgs
10)
Signature / Date / Co stamp.
 APPENDIX I
FORM SDF

Shipping Bill No. ___________________ Date :____________

Declaration under Foreign Exchange Regulation Act, 1973 :

1. I/We hereby declare that I/We am/are the

*SELLER/CONSIGNOR of the goods in respect of which this
declaration is made and that the particulars given in the
Shipping Bill no ______________ dated ________________are true
and that,

A)* The value as contracted with the buyer is same as the full
export value in the above shipping bills.

B)* The full export value of the goods are not ascertainable at
the time of export and that the value declared is that which
I/We, having regard to the prevailing market conditions, accept
to receive on the sale of goods in the overseas market.

2. I/We undertake that I/We will deliver to the bank named

herein _______________ the foreign exchange representing the
full export value of the goods on or before @ ___________________
in the manner prescribed in Rule 9 of the Foreign Exchange
Regulation Rules, 1974.

3. I/We further declares that I/We am/are resident in India and

I/We have place of Business in India.

4. I./We am/are Or am/are not in Caution list of the Reserve

Bank of India.

Date : -

FOR TYCO VALVES & CONTROLS (I) PVT LTD

MR . GANAPATHI
(Signature of Exporter)
 Shipper's Certification for Non - Hazardous Cargo
DHL/AWB no. Airport of Dep. Airport of Dest.
CHENNAI / INDIA
MAWB no.

This is to certify that the articles / substances of this shipment are properly described by name
that they are not listed in the current edition of IATA / Dangerous Goods Regulations ( DGR ),
Alphabetical List of Dangerous Goods,nor do they correspond to any of the hazard classes
appearing in the DGR,Section 3,classification of Dangerous goods and that they are known not to be
dangerous,I.e,not restricted.
Furthermore the shipper confirms that the goods are in proper condition for transportation on
passenger carrying aircraft ( DGR, 8.1.23.) of International Air Transport Association ( I A T A )
Marks and Proper description of goods / give technical name Net Quantity
Number of (Trade Names not Permitted) per package
Packages Specify each article separately)

NET WEIGHT
Shipper
&
Consignee GROSS WEIGHT
Address
on packages

TOTAL
NUMBER of
PACKAGES

FULL NAME
Name & Address of Shipper

DESIGNATION

SIGNATURE & COMPANY STAMP

To be completed in duplicate duly signed & stamped by shipper

ONE COPY to be filed with the AWB copy at ORIGIN & ONE COPY to accompany DEST: AWB
Attach Lab Analysis Report,Material Safety Data Sheet for Bulk-Drugs/ medicines/ Chemicals/ Cosmetics.
pls certify that no hidden dangerous goods are stored or filled in any components or spare-parts.
e.g. Plastic components /Transformer Spares / Elect & Electronic Appliances / for Plastic & Rubber (specify) PVC /etc
Films ( non-nitro-cellulose base ) /
Please note that MSDS is available at www.msdssearch.com
 SHIPPER'S LETTER OF INSTRUCTIONS
Shipper's Name: Consignee's Name:

Invoice Number: Date:

IE CODE NO (10 DIGIT) : Branch Number: (In case of Multiple Offices)
BANK AD CODE # (PART I & II) : Branch Name of Bank:
CURRENCY OF INVOICE
INCOTERMS : F O B / C & F / C & I / C I F :
NATURE OF PAYMENT * : D P / D A / A P / OTHERS
DETAILS TO BE DECLARED FOR PREPARATION OF SHIPPING BILL
FOB VALUE :
FREIGHT (IF ANY) :
INSURANCE (IF ANY) :
COMMISSION (IF ANY) :
DISCOUNT (IF ANY) :
DESCRIPTION OF GOODS TO BE DECLARED ON SHIPPING BILL

NET WT. :

GROSS WT. :

DESCRIPTION OF GOODS TO BE DECLARED ON AWB VOLUME WT. :

DIMENSION (IN CMS) of each pkg.

L X B XH
SPECIAL INSTRUCTION IF ANY,

TYPE OF SHIPPING BILL ( TICK THE

APPROPRIATE) BELOW DETAILS REQUIRED TO BE DECLARED ON INVOICE
a) FREE TRADE SAMPLE (NON-COMM) YES / NO FREE TRADE SAMPLE - VALUE FOR CUSTOMS - NOT FOR SALE
b) DUTY FREE COMMERCIAL YES / NO NOTHING SPECIFIC
c) EOU SHIPPING BILL YES / NO GOODS MANUFACTURED BY EOU & GREEN CARD NUMBER OF EOU
d) DUTY DRAWBACK YES / NO DRAWBACK SL. NO & RATE, PRESENT MARKET VALUE (PMV) OF SHPT
e) DUTIABLE SHIPPING BILL YES / NO RATE OF CESS/ DUTY TO BE PAID AT CUSTOMS
DEPB SL NO., RATE, PRODUCT GROUP CODE, SION ( STANDARD INPUT OUTPUT
f) DEPB SHIPPING BILL YES / NO NORMS) SERIAL NO.
g) DFRC SHIPPING BILL YES / NO DFRC PRODUCT GROUP CODE, SION SL. NO
h) EPCG SHIPPING BILL YES / NO EPCG LICENCE NUMBER & DATE
DEEC REGISTRATION NUMBER AT AIR CARGO, SL. NO. IN PART (E) AND PART (C) IN
i) DEEC SHIPPING BILL YES / NO DEEC BOOK, QUANTITY
j) REPAIR & RETURN YES / NO GOODS BEING EXPORTED ON REPAIR AND RETURN BASIS
GOODS BEING EXPORTED UNDER SECTION 74 ( DUTY DRAWBACK) , IMPORT BILL OF
k) DUTY DRAWBACK (SECTION 74) YES / NO ENTRY AND IMPORT INVOICE NOS.

PLEASE TICK & LIST THE DOCUMENTS (BEING) HANDED OVER TO DHL WITH SHIPMENT :
1. INVOICE (6 originals) 7. ARE-1 FORM IN DUPLICATE 13. ______________________

2. PACKING LIST (6 Originals) 8. VISA/AEPC ENDORSEMENT 14. ______________________

3. SDF FORM IN DUPLICATE 9. LAB ANALYSIS REPORT 15. ______________________

4. NON-DG DECLARATION 10. MSDS 16. ______________________

5. PURCHASE ORDER COPY 11. PHYTOSANITARY CERT 17. ______________________

6. GR FORM/GR WAIVER 12. GSP CERTIFICATE 18. ______________________

- We hereby confirm that the above details declared are true and correct.
- We confirm that our company's IEC & Bank AD Code Details
are registered with EDI System of Air Cargo -
* LC (Letter of Credit) Shipments are not handled by DHL SIGNATURE OF EXPORTER / STAMP
 FREE TRADE SAMPLE
SAMPLE OF BANK CERTIFICATE FOR FREE TRADE SAMPLE

(On the Bank's letterhead)

Dated: ________________

To,

____________________

Subject: Certificate of Free Trade Sample

We certify that to the best of our knowledge and belief, the Free Trade Sample
shipment being exported (details of which are given below) does not involve any
transactions in foreign exchange as informed by the clients.

Name & Address of Shipper:

Name & Address of Consignee:

Description with clear model/serial/part number:

Invoice number and Date:

Value of Goods as per Invoice:

Kindly allow the export of the above detailed goods on Repair & Return basis on
completion of necessary customs and legal formalities.

Thank you,
For, (Bank's Name)

Authorized Signatory
 REPAIR AND RETURN
SAMPLE OF BANK CERTIFICATE FOR REPAIR AND RETURN

(On the Bank's letterhead)

Dated: ________________

To,

____________________

Subject: Certificate of Re-Export

We certify that to the best of our knowledge and belief, the Re-export (details of
which are given below) does not involve any transactions in foreign exchange as
informed by the clients.

Name & Address of Shipper:

Name & Address of Consignee:

Description with clear model/serial/part number:

Invoice number and Date:

Value of Goods as per Invoice:

Reason:

Kindly allow the export of the above detailed goods on Repair & Return basis on
completion of necessary customs and legal formalities.

Thank you,
For, (Bank's Name)

Authorized Signatory
 Quota Charge Statement

We, M/s ____________________________, shipper

confirms that the foreign seller of the goods covered
by invoice number __________________ dated
____________ the best of my knowledge and belief ,
the amount paid to obtain the Export Quota for the
goods was _______________ and paid by
_________________ to __________________ (quota issuing
authority) and such quota charge is/is not included in
the invoice unit price.

Date : _______________________
Signature : _______________________
Title : _______________________

Authorized Signature : _______________________

Address : _______________________
 Single Country Declaration

I, _____________________________ (Name) declare that the articles

listed below and covered by the invoice of entry to which this
declaration relates are wholly the gross product or manufacture
of a single foreign territory or country or insular possession of
the U.S. of fabricated component which are in whole the
product of U.S. as identified below. I declare that information
set forth in this declaration is correct and true to the best of my
information.

A _____________________________ (Country)

B _____________________________ (Country)

C _____________________________ (Country)

D _____________________________ (Country)

Marks of Description of Country of Date of

identification Article & Origin Exportation
Numbers Quantity

Date : __________________________________________

Name : __________________________________________

Signature: __________________________________________

Title : __________________________________________

Company : __________________________________________

Address : __________________________________________
 Multiple Country Textile Declaration

I, (name) declare that the articles described below and covered by the invoice or entry to which
this declaration relates were exported from the countries* identified below on the dates listed and
were subject to assembling, manufacturing or processing operations in, and/or incorporate
materials originating in, the foreign territory or coutries* or inj the U.S. or an insular possession of
the U.S., identified below. I declare that the information set forth in this declaration is correct and
true to the best of my knowledge, information and belief

A. (country*)

B. (country*)

C. (country*)

D. (country*)

Marks of Description of Description of Manufacturing and/or Date and Country of Description Country Date of
Identification Article and processing operations Manufacturing and/or of of Exportation
Numbers Quantity processing Material Production
Country Date of
Exportation

Name:
Signature:
Title:
Company:
Address:
Date:
Country or countries when used in this declaration includes territories and U.S. insular
possessions. The country will be identified in the above declaration by the alphabetical
designation appearing next to the named country.
 Negative Declaration
(Negative declaration is required to be submitted by the Shipper when exporting Silk Garments, Fabric, Made-
ups, where the content is more than 70%, to the USA)

I, ________________________________ declare that the articles described

below and covered by the invoice of entry to which this declaration
relates are not subject to SECTION 204 Agricultural Act of 1956, as
amended (7 USE 1854) and the information set forth in this declaration is
correct and true to the best of my information, knowledge and belief.

Marks of identification Description of Article & Country of Origin

Numbers Quantity

Made in India

Date : __________________________________________

Name : __________________________________________

Signature : __________________________________________

Title : __________________________________________

Company : __________________________________________

Address : __________________________________________
 TOXIC SUBSTANCES CONTROL ACT
(TSCA) CERTIFICATION

Date :

(Check one section only)

[ ] POSITIVE CERTIFICATION:
"I certify that all chemical substances in this shipment comply with
all applicable rules and orders under TSCA and that I am not offering a
chemical substance for entry in violation of TSCA or and applicable
rule or order hereunder."

OR

[ ] NEGATIVE CERTIFICATION:
TSCA."

Company Name:

Company Address:

Authorized Name:

Authorized Signature: _________________________

Title:

AIR WAYBILL:

If the certifier is unsure if them chemical substance is subject to TSCA

compliance, contact the environmental protection agency, TSCA
Assistance Office, D. C. (202) 554-1404 between 8:30 a.m. - 5:00 p.m.
E.T

Date :
 APPENDIX -C1
OFFICE OF THE SUPERINTENDENT OF CENTRAL EXCISE

Range __________________ Division ___________________

Commissionerate ____________________________________
C. No. Date
Shipping Bill No.* Date

1.Name of EOU :
2.IEC No. (of the EOU) :
3.Factory address :
4.Date of examination :
5.Name and designation of the examining :
Officer-Inspector/EO/PO
6.Name & designation of the supervision :
Officer-Appraiser/Superintendent
7. (a)Name of Commissionerate/Division/Range :
(b)Location Code** :
8.Particulars of Export Invoice :
(a)Export Invoice No. :
(b)Total No. of packages :
(c)Name and address of the consignee abroad :
9.(a)Is the description of the goods, the Quantity and their :Yes/No
value as per particulars
(b)Whether furnished
sample is drawn for in the forwarded
being export invoice?
to port of :Yes/No
export?
10.(a)For Non-containerized cargo
Nos. of packages :Seal Nos
(b)For Containerized cargo :
Container No. Size Seal No.

Signature of Signature of Signature of

Exporter Examiner/Inspector Appraiser/Superintendent
Name : _____________ Name : _____________ Name : _____________
Designation : _________ Designation : _________ Designation : _________
Stamp: Stamp: Stamp:
Note:
1. The office supervising the examination should attest Invoice(s) and any other document
accompanying
2. * To be filledthis document.
in by the exporter before filing of this document at the time goods registration in the
export shed.
3. * Revised 6 digit code as assigned by the Directorate of S & I, XXYYZZ
XX Commissionerate
YY Division
ZZ Range
 A P P E N D I X -- I I (ANNEXURE D)
DEPB DECLARATION
( To be filled for export goods under claim for drawback )

Shipping Bill No. and Date:- / 2000

I / We ( Name of the Exporter ) do hereby

further declare as follows:-

1) That the quality and specification of goods as stated in this Shipping Bill are in accordance with the terms of
exports contract entered into with the buyer / consignee in pursuance of the goods which are being exported.

2) That we are not claiming benefit under " Engineering Products Export ( Replenishment of Iron and Steel
Intermediates ) schemes" notified vide Ministry of Commerce Notification No.539 RE / 92-97 dated 01.03.95.

3) That there is no change in the manufacturing formula and in the quantum per unit of the imported material or
components,utilised in the manufacture of theexport goods, and that the materials or components which have
been stated in the application under Rule 6 or Rule 7 of the of Drawback Rules 1995 to have been imported
continue to be so imported and are not been obtained from indigenous sources.

4) * ( A ) That the export goods have not been manufactured by availing the procedure under Rule 12(1)(b)/13(1)(b)
of the Central Excise Rules,1944.

OR
* ( B) That the export goods have been manufactured by availing the procedure under rule 12(1)(b)/13(1)(b) of the
Central Excise Rules,1944,but we are / shall be claiming DBK on the basis of special brand rate in terms of Rule 6
1995)

5) *( A ) That the goods are not manufactured and / or exported in discharge of export obligation against an
Advance license issued under the Duty Exemtion Scheme (DEEC) vide relevant import and Export policy
in force.
OR

* ( B ) That goods are manufactured and are being exported in discharge of export obligation under the
Duty Exemption Scheme ( DEEC ) , in terms of Notification 79 / 95 Cus,or 80/85 Cus, both dated
31.03.95 or 31/97 dated 01.04.97 but I / We are claiming Drawback of only the Central Excise portion
of the duties on inputs specified in the Drawback Schedule.

* ( C ) That the goods are manufactured and are being exported in discharged of export obligation
under the duty exemption scheme ( DEEC ), but I / We are claiming Brand rate of fixed under Rule 6 or
& of the DBK Rules,1995.
* ( Strike out which ever is inapplicable)

6) That the goods are not manufactured and / or exported after availing of the facility under the Passbook
Scheme as contained in para 7.25 of the Export and Import Policy ( April,1997-31st March,2002).
7) That the goods are not manufactured and / or exported by unit licensed as 100% Export Oriented Unit in terms
of Import and Export Policy in force.

8) That the goods are not manufactured and / or exported by a unit situated in any Free Trade Zone / Export
Processing Zone or any other such Zone.

9) That the goods are not manufactured partly or wholly in bond under Section 65 of the the Customs Act,1962.

10) That the present market value of the goods is as follow :-

S. No. Item No. In Invoice Market Value

11) That the export value of the goods covered by this Shipping Bill is not less than total value of all
imported materials used in manufacture of such goods.

12) That the market price of the goods being exported is not less than the drawback amount being
claimed.

13) That the drawback amount claimed is more that 1% of the FOB value of the export produst,or the
drawback amount claimed is less than 1% of the FOB value but more than Rs.500/- against the
Shippin Bill.

14) I / We undertake to repatriate export proceeds with 6 months from date of export and submit BRC
to Asst: Commissioner ( Drawbck ) In case,the export proceed are not realised within 6 months
from the date of the export, I / We will either furnish extension fo time frm RBI and submite BRC
within such extended period or will pay back the drawback received against this Shipping Bill.

Name of Exporter
Address

Signature of the Exporter

 APPENDIX II
DEEC Declaration

(To be filled for export of goods under DEEC scheme)

Shipping Bill No. & Date: _________________________________

I/We ___________________________ (name of the exporter) do hereby further declare as follows:

1.

A. That the export goods have not been manufactured by availing the procedures under rule 12(I)
(b)//13(I)(b) of the Central Excise Rules, 1994.

OR

B. That the export goods have not been manufactured by availing the procedure under rule 12(I)
(b)/12(I)(b) of the Central excise Rules, 1994 in respect of the materials permitted to be imported
duty free under the relevant license except the benefit under the notificatiion number 49/94-CE
(NT) dated 22/09/94.

OR

C. That the export goods have been manufactured by availing the procedure under rule
12(I)(b)/13(I)(b) of the Central Excise Rules, 1994.

OR

2.

A. (A) The export against this shipping bill is made directly by advance license holder

OR

B. The export against this shipping bill is being made directly by third party(s) and a contractual
agreement in this regard exists between the advance license holder and third party. all the
export documents are signed by both advance license holder and exporter. In the event of any
fraud – both will be severally and jointly responsible for such fraud and liable for penal action.

(* Strike out whichever is inapplicable)

Name of the Exporter :

Signature of the Exporter

 ANNEXURE-I
Exporters' Declaration required for Exports of Woven Garments for availing
higher All Industry Rate of Drawback.
(Circular No.54/2001-Cus, dated 19th October, 2001).
1. Description of the Goods:

2. Invoice No. and Date:

3. Name and address of the Exporter alongwith

the name of the jurisdictional Central Excise
Commissionerate/Division/Range:

4. Name of the Supporting Manufacturer (s)/

Job worker (s) alongwith the name of the
Jurisdictional Central Excise Commissionerate/
Division/ Range:

5. Address of the Manufacturing Unit(s)/

Job Work Premises:
We, M/S. ____________________, the Exporters of the above mentioned goods, hereby declare
that -
(a) we are not registered with Central Excise authorities,
(b) we have not paid any Central Excise duty on these goods, and
(c) we have not availed of the Cenvat facility under the CENVAT Credit Rules, 2001 or any
notification issued thereunder, and
(d) we have not authorized any supporting manufacturer/job-worker to pay excise duty and
discharge the liabilities and comply with the provisions of Central Excise (No.2) Rules,
2001, under the proviso to Rule 4(3) of the said Rules.
We also undertake that in case it is discovered that the Cenvat facility has been availed by us
or by our supporting manufacturers in respect of these export goods, we shall return the
excess drawback paid to us on the basis of above declaration.

Exporters' Signature & Seal

 ANNEXURE-II
Supporting Manufacturers'/Job Workers' Declaration required for Exports of Woven Garments for
availing higher All Industry Rate of Drawback.
(Circular No.54/2001-Cus, dated 19th October, 2001).

1. Description of the Goods:

2. Invoice No. and Date:

3. Name and address of the Exporter alongwith

the name of the jurisdictional Central Excise
Commissionerate/Division/Range:

4. Name of the Supporting Manufacturer (s)/

Job worker (s) alongwith the name of the
Jurisdictional Central Excise Commissionerate/
Division/ Range:

5. Address of the Manufacturing Unit(s)/

Job Work Premises:
We, M/S. ____________________, the supporting manufacturers/job workers declare that we
(a) are not registered with Central Excise authorities,
(b) have not paid any Central Excise duty on these goods, and
(c) have not availed of the Cenvat facility under the CENVAT Credit Rules, 2001 or any
notification issued thereunder, and
We also declare that we are manufacturing and supplying garments to the above merchant
exporters only.

Supporting Manufacturers'/Job Workers' Signature & Seal

 APPENDIX III
(To be filled for export goods under claim for drawback)

Shipping Bill no. and date_____________________

I/We__________________________________do hereby further declare as follows:-

1. That the quality and specification of the foods as stated in this Shipping Bill are in accordance with the
terms of the exports contract entered into with the buyer/consignee in pursuance of which the goods are
being exported.

2. That we are not claiming benefit under "Engineering Products Export (Replenishment of Iron and Steel
Intermediates) Scheme" notified vide Ministry of Commerce Notification No.539RE/92-97 dated 01.03.95.

3. That there is no chance in the manufacturing formula and in the quatum per unit of the imported
material or components, if any, utilized in the manufacture of the export goods and that the materials or
components which have been stated in the application under Rule 6 or Rule 7 to have been imported,
continue to be so imported and are not been obtained from indigenous sources.

4. A. That the export goods have not been manufactured by availing the procedure under rule 191A/191B
or under Rule 12(1)(b)/13(1)(b) of the Central Excise rules,1944.

OR

B.That the export goods have been manufactured by availing the procedure under rule 191A/191B or under
Rule 12(1)(b)/13(1)(b) of the Central Excise rules,1944.

5. A. That the goods are not manufactured and/or exported in discharge of export obligation against an
Advance Licence issued under the Duty Exemption Scheme (DEEC) vide relevant Import and Export Policy
in force.

OR

B. That goods are not manufactured and are being exported in discharge of export obligation under the
Duty Exemption Scheme (DEEC),but I/We are claiming drawback of only the Central Excise Portion of the
duties on inputs specified in the Drawback Schedule except for the Central Excise Portion of duties on
inputs permitted import free of Addl. Duty of customs against Advance Licence.

6. That the goods are not manufactured and/or exported after availing of the facility under the Passbook
Scheme as contained in para 54 of the Export and Import Policy (April. 1992 -31st March, 1997).

7. That the goods are not manufactured and/or exported by a unit licensed as 100% Export Oriented Unit in
terms of Import and Export Policy in force.

8. That the goods are not manufactured and/or exported by a unit situated in any Free Trade Zone/Export
Processing Zone or any such Zone.

9. That the goods are not manufactured partly or wholly in bond under Section 65 of the Customs Act,
1962.
 10. That the present Market Value of goods is as follows:-

S.No ITEM NO. INVOICE MARKET VALUE

11. That the export value of the goods covered by this Shipping Bill is not less than the total value of all
imported materials used in manufacture of such goods.

12. That the market price of the goods being exported is not less than the drawback amount being claimed.

13. That the drawback amount claimed is more that 1% of the FOB value of the export product or the
drawback amount claimed is less than 1% of the FOB value but more than Rs.500.00 against the Shipping
Bill.

14. I/We undertake to repatriate export proceeds within 6 months from date of export and submit B.R.C to
Asstt. Commissioner (Drawback). In case, the export proceeds are not realized within 6 months from the
date of export, I/We will either furnish extension of time from R.B.I and submit B.R.C within such extended
period or will pay back the drawback received against this shipping bill.

Date___________

For (Name of Company)

NAME AND SIGNATURE OF THE EXPORTER

(* Strike out whichever is not applicable)

 APPENDIX IV
(Declaration to be filed in respect of goods for which drawback under S.S.Nos.

03.01,03.02, 04.01, 04.02, 04.03, 07.01, 07.02, 07.03, 08.01,08.02, 08.03, 09.01, 09.02,
09.03, 16,01 16.02, 16.03, 1,7.01, 17.02, 17.03, 18.01, 18.02, 18.03. 19.'01, 19.02, 19 .
03 ,20.01 20.02 , 20.03, 20.06, 20.07, 20.10, 20.11, 20.12, 20.15, 20.16, 20.17, 21.01,
21.02, 21.03, 39..01, 39.03, 39.05, 39.06, 39.07, 39.09, 39.11, 39.12, 39.13, 39.14,
39.15, ,39.16, 3,9.18, 39.19, 39.20, 39.24, 39.25, 39.27, 39.29, 40.06, 42.01, 42.02,
42.05, 42.06, 42.07, 42.10, 42.12, 42.14, 52,.01, 52.03, 52.04, 52.05, 54.03, 54.04
54.05, 54.06, 55.01, 55.02, 55:03, 55.04, 55.05, 56,04, 58.01, 58.02, 58.03, 58.04,
60.06, 60.10, 61.02, 61.05, 61.07 62.02, 62.09, 62.10, 62.21, 63.03, 63.04, 63.061,
63.062, 63.07, 63.08, 63.10, 63.11, 64.01, 64.02, 64.03, 64.06, 64.07, 64.08, 64.09,
64.11, 71.02, 71.03, 71.05, 73.03, 73.11, 73.13, 73.15, 73.22, 74.02, 74.04, 74.05,
74.06, 74.07, 74.12, 74.17, 74.19, 74.20, 74.24, 76.03, 76.04, 82.01, 82.03, 82.031,
82.032, 83.07, 84.26, 84.54, 84.58, 85.37, 85.38, 85.39, 85.40, 85.45, 85.120, 85.154,

Shipping Bill Number & Date .....................

I/We__________________________ (Name of the

Exporter) do hereby declare as follows:-

1. That no CENVAT facility has been availed for any of the inputs used in the manufacture
of export products; and

2. That the goods are being exported under bond 'or claim for rebate of Central Excise
duty and a certificate from concerned Superintendent of Central Excise, incharge of
factory of production, to the effect that CENVAT facility has not been availed for the
goods under export, is enclosed (Drawback as per schedule is applicable).

(Name, Address & Signature of the Exporter)

APPENDIX V
(Declaration Lo be filed for goods falling under
S.S.No.28.26,28.261,29.15,29.16,30.01,30.02)

Shipping Bill Number & Date...............

I/We __________________(Name of the Exporter) declare that the

drugs and pharmaceuticals under export are other than the following:-

1. Distilled water for injections as per pharmacopoeial standards.

2. Ayurvedic, Homeopathic, Sidha and crude drugs

3. Tincture and saline preperations

4. Medicinal Castor Oil.

5. Isogel

6. Calcium Senoside

7. (a) Gripe Water

(b) Gelatine Capsules

(c) Surgical Spirit

(d) Ether Anesthetic B.P.

(e) Sesame Oil B.P

(f) Strychnine Alkaloid

8. Senna Calcium precipitation 20%

9. Intestopan Tablets

10. Drugs and pharmaceutical products extracted/manufactured wholly or partly from plants and
animals.

11. Drugs and pharmaceutical products containing any of the goods specified in Notification
No.16/2000-Cus. dt.1.3.2000 which are fully exempted from duty.

(Name, Address & Signature of the Exporter)

APPENDIX VII
(Declaration to be filed in respect of goods of S.S.No.30.04, 30.05, 30.06, 30.07, 30.08, 30.09, 30.11,
30.12 & 30.14)

Shipping Bill Number & Date............

I/We ______________________________(Name of the Exporter) declare that:-

*1. The grammage of tablets indicates the extent of active ingredient contained in the tablets.
(Drawback as per schedule is permissible).

*2. The grammage of tablets is as shown in invoice but the active ingredient content is ________%
only and the drawback

claimed has been reduced to the percentage of active ingredient.

(*Strike out whichever is not applicable)

(Name, Address & Signature of the Exporter)

APPENDIX VIII

(Declaration to be filed in respect of goods of S.S.No.30.03) Shipping Bill Number & Date. ............

I/We ______________________________________(Name of the Exporter) declare that Mercury free

hydrochloric acid (not exceeding the limit of 0.02 ppm of mercury in hydrochloric acid) has been used
in the manufacture of export product and a certificate from Supdt. of Central Excise in this regard is
enclosed.

(Name, Address Sc Signature of the Exporter)

APPENDIX IX
(Declaration to be filed in respect of goods for which drawback S.S.Nos.48.03, 48.04, 48.05, 48.06,
48.07, 48.08, 48.09, 49.03, 49.04, 49.05, 49.06, 49.07, 49.08 & 49.09)

Shipping Bill Number & Date...................

I/We ___________________________(Name of the Exporter)

declare that the goods under export are made of only one type of paper/board and if made of more
than one type of paper/board, drawback is being claimed only on the quantity of paper falling under
S.S.Nos. 48.03, 48.04, 48.05, 48.06, 48.07, 48.08, 48.09, 49.03, 49.04, 49.05, 49.06, 49.07, 49.08 &
49.09, as the case may be.

(Name, Address & Signature of the Exporter)

APPENDIX - X

(Declaration to be filed in respect of Drawback claims for S.S.No.72.01/ 72.03, 72.05, 72.07, 72.09,
72.11, 87.13, 87.14, 87.15 87.16,87.17, 87.18, 87.19, 87.20, 87.21, 87.22, 87.23, 87.24, 87.25 87.26,
87.27, 87.28, 87.29, 87.30, 87.31, 87.32, 87.33, 87.34, 87.35 87.36, 87.37, 87.38, 87.39, 87.40,
87.41, 87.42, 87.43 & 87.44)

Shipping Bill Number & Date...........

I/We ____________________________ (Name of the Exporter) declare that the export products are
made out of only imported HR Steel/Strip/Wide Coils and such imported inputs are duty paid.

(Name, Address & Signature of the Exporter)

 APPENDIX - XI
(Declaration to be filed in respect of Drawback claims for S.S.No.73.10, 73.18, 73.20, 73.24, 84.01,
84.02,84.03, 84.04, 84.05, 84.06, 84.061, 84.062, 84.60, 84.61.,& 87.12). !

Shipping Bill Number & Dace ...........

I/We ______________________________(Name of the Exporter) declare that duty paid imported

steel has been used in the manufacture of the export product and declaration to this effect is made on
the Shipping Bill invoice and a certificate from Supdnt. of Central Excise, incharge of factory of
production to this effect is enclosed.

(Name, Address & Signature of the Exporter)

APPENDIX-XIII
(Declaration to be filed in respect of goods for which drawback under S.S.No. 84.10, 84.11 & 84.12)
Shipping Bill Number & Date...................

I/We____________________________________(Name of the Exporter) declare:-

*1. That the FOB prices as per order/contract/invoice and shipping documents for centrifugal pump
and electric motor are not available seperately in respect of "Power driven centrifugal pumps for
liquids fitted with electric motors" under export. (Drawback @ 2.5% is admissible).

*2. That the FOB. value of centrifugal pumps and electric motors is seperately available as per
order/contract and same is seperately shown on the invoice and shipping documents. We have shown
price of pumps and motors seperately in Annexure. 'B' . The value of Motor has been shown under
S.S. No______ and that of pump under S.S.No. ____

(* Strike out whichever is not applicable).

(Name, Address & Signature of the Exporter)

APPENDIX-XIV
Declaration to be filed by the exporters of Leather Articles claiming All Industry Drawback Rate in the
Drawback Table for the year 1999-2000.

I/We ..................................(Name of the Exporter)

declare that the goods exported in the S/Bill No..............dt......... are manufactured from the
indegenous finished leather in which there is no content of duty free imported leather.

Name, Address & Signature of the Exporter or his authorised agent.