Note: 1. Please see Para 7.46 of this Handbook 2. Please read the general instructions given Appendix 1 before filling this application. 3. In addition to 2 copies of this application form, please also submit Appendix- 1A (in duplicate) alongwith this application. -------------------------------------------------------------------------------------- FOR OFFICIAL USE File No. Date: -------------------------------------------------------------------------------------- 1. Name and address :........................................... of the Applicant :........................................... 2. IEC Number :........................................... 2(a) PAN Number :........................................... 3. Total FOB value of :In figures Rs .............................. Exports realised :In words Rs ................................ 4. Total DEPB entitlement claimed (in Rs.) : In figures Rs ............................. : In words Rs ............................... 5. Details of exports made
----------------------------------------------------------------------------

S.No	S/Bill No and Date	FOB value as per Shipping Bill	Customs House	Bank Certificate No.and Date
(1)	(2)	(3)	(4)	(5)
Product group code No.	SI. No. of DEPB rate list (App.28A)	Discription as per s/Bill	FOB as per Bank Certificate	DEPB Rate	Valu of DEPB earned (Rs.)
(6)	(7)	(8)	(9)	(10)	(11)

 Total:...................................................................  

 Note:  For Product Group Code No. refer to appendix-1.  
  

 6. DEPB already claimed on pre export basis 


"
	


	
S.no
	
File No and name of licencing authority
Value(Rs.)
	
DEPB No.and date


	
 
	
 
	
 
	
	
 


	
 
	
 
	
 
	
 




        

 7.  Balance value for  which DEPB  Rs.:....................................... 
     is to be issued on  

  				OR  

 Balance value of DEPB on which  
 duty and interest is payable. 

 8.  Application fee for DEPB:   Rs.........................................  
  

 Bank Receipt/DD No. and date : .......................................... 
 Issued by                    : .......................................  
  

		                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 (Applicable only in case of exports made against  
 irrevocable Letter of Credit). 
  

    				Signature of the Applicant:..................  
                           	Name : .......................  
                         	Designation : .......................  
                       		Official Address : .......................  
              			Tele.No. : .......................  

 Place : 
 Date :            		Email Address : .......................  
  

 -------------------------------------------------------------------------------------- 
		 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.