I/We hereby solemnly affirm and declare that customs purpose copy/exchange purpose copy/both the copy of Licence No. / Authorisation No.___________dated__________ issued to me/us has been lost/misplaced, without having been registered with any Customs House / after having been registered with _______________ (Customs House) and not utilised at all/ utilised partly. The total amount for which the Licence / Authorisation was issued is Rs. (figure and words ____________) and the total amount for which the duplicate is now required is to cover the balance of Rs.__________. Licence / Authorisation has not been cancelled, pledged, transferred or handed over by me/us or on my behalf to, any other party for any purpose/consideration whatsoever. I/We request to cancel the original Licence / Authorisation in lieu of which the duplicate copy has been applied for by me/us. I/We agree and undertake to return the original Licence / Authorisation, if traced later, to the issuing authority for record
 

1. Bank Receipt (in duplicate)/Demand Draft evidencing payment of application fee in terms of Appendix 21B.

2. Copy of First Information Report (FIR).