::::: Paramount Couriers :::::
ANNEXURE-B

DECLARATION FORM FOR EXPORT OF GOODS UNDER CLAIM FOR DRAWBACK

To be filled in by the Service Centre

Date of Presentation Job No. Date :

Bill No: Date :

Signature

To be filled in by Exporters/C.H.A.

1. RBI Ten digit code:
2. CHA Licence No:                                                Name:
3. (a) IEC Code No:
    (b) Name & Address of Exporter:
                                                                                               
    (c) Exporter Type:                                                           (a)[P] Private / [G] Government
                                                                                               (b)[R] Merchant / [F] Manufacturer
4. A/C No. of the Exporter (in the State Bank of India A.C.C. Mumbai ) :
5. (a) Type of Export House:                                             [EH] Export House
                                                                                               [SH] Star Trading House
                                                                                               [SS] Super Star Trading House
    (b) Certificate No.:

6. State of origin of export goods (Maharashtra/Gujarat/Goa etc.):
7. Consignee Name & Address:
8. Cosnsignee Country:
9. Port of Destination:
10. Final Destination Country:
11. (a) Name & Address of the Authorised :
             Dealer /Bank through which export proceeds to be realised:
      (b) Account No.:
      (c) Authorised Dealer Code:
12. (a) GR-1 No.:                                                                 Date:
       (b) RBI Waiver No:                                                        Date:
             Invoice Details:
13. Invoice Number:                                                            Date:
14. (a) Whether consignee and Buyer are same:         (YES/NO)
      (b) if No, Buyer's Name & address:
15. Currency of Invoice:
16. Export Contract No:
17. Nature of Payment:                                                       [LC] Letter of Credit
                                                                                                [DA] Delivery against Acceptance
                                                                                                [DP] Delivery against Payment
                                                                                                [AP] Advance Payment
18. Period of payment as per Contract (No. of Days):
19. (a) Nature of Contract:                                                 [1] FOB [2] CIF [3]CF [4] CI
       (b) Whether unit price includes:                                [F] Freight [I] Insurance
                                                                                                [B] Freight & Insurance
                                                                                                [N] None
       (c)

RATE CURRENCY AMOUNT

Discount
Commission
Other Deductions
Packing & Misc. Charges
Freight
Insurance
(d) Name & Address of the person to whom the commission is paid :

20. Item-wise Details

Item Sl.No: RITC Generic & Item Description Qty A/C Unit Unit Price
1 2 3 4 5 6

Duty Drawback Details
S.S No.Of DBK Sch. Apdx No.Of Public Notice Cond No.in Appdx Qty For DBK A/C Unit DBK Rate Claimed Brand Rate Regn No.
7 8 9 10 11 12 13

21. INFORMATION ON RAW MATERIALS
    (To be given where Drawback claimed is on the basis of Raw Materials used)

Invoice No: Item No: Raw Material Sl.No: Description Qty A/C Unit Rate at Which DBK Claimed




22. QUOTA RELATED INFORMATION

QuotaCertificateNo/Export LicenceNo:

Agency Name (AEPC/CTEPC/APEDA):

Expiry Date:

Date:

Declaration

I.   I/We declare that the particulars given herein above are true and correct

II.  I/We enclose herewith the copies of the following documents(to be submitted with the export goods in the warehouse)

1. GR Declaration
2. DBK Declaration
3. DEEC Declaration
4. Invoice
5. Quota/inspection etc. Certificates
6. Other (specify)

Name of the Exporter Name of CHA:
Designation Designation:
Signature Signature:
ID Card No:
Dated :

Instructions

1. All entries to be made in capital letters
2. Documents should be typed or neatly hand written
3. Photocopy of Invoice has to be attached separately with declaration form for Data Entry.

 

 

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