Note: 1. Please see Paragraph 7.38 of this Handbook 2. Please read the general instructions given Appendix 1 before filling this application. 3. Please submit 2 copies of this application form. FOR OFFICIAL USE F. NO................................... Date:............... 1. Name and address of the :.................................................. applicant ................................................... ................................................... 2 (a)IEC Number :.................................................. (b)PAN Number :.................................................. 3. FOB value of exports In figures :Rs.................................... In words :Rs.................................... 4. Total DEPB entitlement In figures :Rs.................................... claimed In words :Rs.................................... 5. Application fee Rs................................................. Bank Receipt/DD No.& Date :.................................................. Issued by ................................................... ................................................... 6. Details of export made

Si.No	s/Bill No DEFB Rate List (App.28A)	FOB value as per s/Bill	Customs House	Date of Export	Bank Certificate and date
1	2	3	4	4 a	5

Product Group Code No.	SI. No. of DEPB Rate List (APP.28A)	Discription as per s/Bill	FOB as per Bank Certificate including the commission, Upto the specified limit	DEPB Rate	Value of DEPB Claimed (Rs.)
(6)	(7)	(8e)	(9)	(10)	(11)

Total: Note: For Product Group Code No. refer to appendix-1. DECLARATION / UNDERTAKING ----------------------------- 1. I / We hereby declare that the particulars and the statements made in this application are true and correct to the best of my / our knowledge and belief and nothing has been concealed or held therefrom. 2. I / We fully understand that any information furnished in the application if proved incorrect or false will render me / us liable for any penal action or other consequences as may be prescribed in law or otherwise warranted. 3. I / We undertake to abide by the provisions of the Foreign Trade (Development and Regulation) Act, 1992, the Rules and Orders framed thereunder, the Export and Import Policy and the Handbook of Procedures. 4. I / We hereby declare that no DEPB has been claimed earlier pertaining to the particulars of the Shipping Bills given above. 5. I / We further declare that no export proceeds are outstanding beyond the prescribed period as laid down by the RBI, or such extended period for which RBI permission has been obtained. 6. I hereby certify that I am authorised to verify and sign this declaration as per Paragraph 3.8 of the Policy. 7. I / We further declare that in case of non realisation of export proceeds or lesser realisation of export proceeds, we shall pay,in cash, an amount equivalent to the duty free import benefits availed against DEPB entitlement already obtained on the non realised or lesser realised value of export proceeds together with 24% interest reckoned from the date of duty free imports to the date of payment. Signature of the Applicant: .............. Name: .................. Designation: .................. Official address: .................. .................. Tele No: ................. Email Address: ................ Date: Place : -------------------------------------------------------------------------- Documents to be enclosed with the application form -------------------------------------------------------------------------- 1. Bank Receipt (in duplicate) / Demand Draft evidencing payment of application fee in terms of Appendix-34. 2. E.P Copy of DEPB shipping Bills. 3. Bank certificate of Exports and Realisation in Appendix - 25.