APPENDIX - 9A

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STATEMENT OF EXPORT/ REDEMPTION FORM UNDER EPCG SCHEME

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NOTE: PLEASE SEE PARAGRAPH 5.9 AND 5.13 OF THIS HANDBOOK

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a)	Name & Address of the Licence holder	:
b)	EPCG Licence No. & Date	:
c)	CIF Value	(i) Issued : (ii) Utilised :
d)	Export Obligation w.r.t imports effected under the EPCG Licence.	:
	(i) Export obligation equal to five times of the CIF value of import/deemed import of capital goods or eight times the duty saved on import/deemed import of capital good as the case may be. (S. No. (d)(i) has been amended vide PN. No. 8/2003, Dt. 14/05/2003) [OLD- i) Export obligation equal to five times of the duty foregone on import/ deemed import of capital goods or eight times the duty saved on import/ deemed import of the capital goods as the case may be.]	:
	ii) Average exports to be maintained.	:
e)	Product exported as per the conditions attached to the EPCG licence	:
f)	Date of clearance of the first consignment of capital goods under the EPCG Licence from the customs authorities/Date of receipt of CG from indigenous source	:
g)	Date of completion of export obligation	:
h)	Details of Exports	:
	i) Year/Block of year from the date of issue of licence:	:
	ii) Proportion of total Export Obligation fulfilled:	:
	iii) Details of physical/ deemed exports:

S.No.	Product Exported/ Supplied	Shipping Bill No./Date/Lorry/ Railway receipt number and date	FOB value of exports/ FOR value of supplies				Remarks
			Exports/Supplies made/capable of being made out of imported capital goods to discharge export obligation imposed on the Licence and export proceeds realised
			Direct exports	Third Party exports	Deemed exports	Royalty payments in FCC
(1)	(2)	(3)	(4a)	(4b)	(4c)	(4d)	(5)

iv) We further declare that we have made exports of US$/Rupee________ in the licensing year _________ for maintenance of average (other than that mentioned in iii) above).

We hereby declare that the above particulars are correct

Signature with seal and
Designation of the exporter

It is certified that we have verified the books of accounts of the above exporter and the particulars given above in respect of exports both physical and deemed, are correct. It is also certified that all the shipping bills verified by me/us as mentioned in iii) above contained in the EPCG Licence No. and date as given at Sl.No.b) above.

Signature with seal of the
Chartered Accountant/Cost
& Works Accountant
Membership No.

This is certified that all physical exports as shown in iii) & iv) above are in freely convertible currency and payment of the same has been realised.

Signature with the seal of the Bank

Date:

Bank Code No.

Note:

1. The consolidated statement may be submitted only at the time of seeking redemption of BG/LUT and the statement should be complete in all respects including the information in S.No.(3)column (4) above duly certified by Chartered Accountant as well as by the Bank.

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Documents to be enclosed with the application form:

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1). Copy of licence showing the date of clearance of the first consignment.

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