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

Vessel / Flight No.

Port of Loading

CIF

C&F /

FOB

ADVANCEPAYMENT RECEIVED FOR GOODS

Payment Terms:

Port of Discharge

Final Destination

Marks & Numbers.

No. & kind of

Container No.

Amount chargeable :

DP

Description of Goods

DA

AP

/
Quantity

Rate

KGS

TOTAL

( in words / currency )

Declaration:
We declaration that invoice shows the actual price of goods
described and that all particularss are true & correct.

Signature / Date / Co stamp.

Amount

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

Marks & Numbers.

No. & kind of

Container No.

Packages

Net weight:

Gross weight :

Description of Goods

Quantity

Remarks

Carton No.
Box No.

**
L ( cms )

B ( cms )

L X B X H cms3 / 6000 =

H ( cms )

1)
2)

Volumetric weight:

Kgs

Actual weight:

Kgs

Total Net weight

Kgs

Total Gross weight

Kgs

3)
4)
5)
6)
7)
8)
9)
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
Number of
Packages

Proper description of goods / give technical name

(Trade Names not Permitted)
Specify each article separately)

Net Quantity
per package

NET WEIGHT
Shipper
&
Consignee
Address
on packages

GROSS WEIGHT

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) :

BANK AD CODE # (PART I & II) :
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)
:

Branch Number:
(In case of Multiple Offices)
Branch Name of Bank:

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)

a) FREE TRADE SAMPLE (NON-COMM)
YES / NO
b) DUTY FREE COMMERCIAL
YES / NO
c) EOU SHIPPING BILL
YES / NO
d) DUTY DRAWBACK
YES / NO
e) DUTIABLE SHIPPING BILL
YES / NO
f) DEPB SHIPPING BILL
g) DFRC SHIPPING BILL
h) EPCG SHIPPING BILL

YES / NO
YES / NO
YES / NO

i) DEEC SHIPPING BILL

j) REPAIR & RETURN

YES / NO
YES / NO

k) DUTY DRAWBACK (SECTION 74)

YES / NO

BELOW DETAILS REQUIRED TO BE DECLARED ON INVOICE

FREE TRADE SAMPLE - VALUE FOR CUSTOMS - NOT FOR SALE
NOTHING SPECIFIC
GOODS MANUFACTURED BY EOU & GREEN CARD NUMBER OF EOU
DRAWBACK SL. NO & RATE, PRESENT MARKET VALUE (PMV) OF SHPT
RATE OF CESS/ DUTY TO BE PAID AT CUSTOMS
DEPB SL NO., RATE, PRODUCT GROUP CODE, SION ( STANDARD INPUT OUTPUT
NORMS) SERIAL NO.
DFRC PRODUCT GROUP CODE, SION SL. NO
EPCG LICENCE NUMBER & DATE
DEEC REGISTRATION NUMBER AT AIR CARGO, SL. NO. IN PART (E) AND PART (C) IN
DEEC BOOK, QUANTITY
GOODS BEING EXPORTED ON REPAIR AND RETURN BASIS
GOODS BEING EXPORTED UNDER SECTION 74 ( DUTY DRAWBACK) , IMPORT BILL OF
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
identification
Numbers

of Description
of Country of Origin Date
Article & Quantity
Exportation

of

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

Identification

Article and

processing operations

Manufacturing and/or

Numbers

Quantity

processing
Country

Description Country
of

of

Date of
Exportation

Material Production

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
Numbers

Description of Article &

Quantity

Country of Origin

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:
"I certify that all chemicals in this shipment are not subject to 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 value as
(b)Whether sample is drawn for being forwarded to port of export?
10.(a)For Non-containerized cargo
Nos. of packages
(b)For Containerized cargo
Container No.
Size

:
:
:
:
:

Signature of
Exporter
Name : _____________
Designation : _________
Stamp:
Note:

Signature of
Appraiser/Superintendent
Name : _____________
Designation : _________
Stamp:

Signature of
Examiner/Inspector
Name : _____________
Designation : _________
Stamp:

:
:
:
:
:
:
:
:Yes/No
:Yes/No
:Seal Nos
:
Seal No.

1. The office supervising the examination should attest Invoice(s) and any other document accompanying this
2. * To be filled 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
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
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
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, 87.45, 90.07, 94.01, & 95.08 has been claimed).
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.