Exporter

Invoice No.& Date

SB No.& Date

AR4/AR4A No.& Date

Q/Cert No.& Date

Importer-Exporter Code No.

Consignee

Export Trade Control

If export under:

Deferred Credit [ ]

Joint Ventures [ ]

Rupee Credit [ ]

Others [ ]

RBIs Approval/Cir.No. & Date

Custom House Agent L/C.No.

Pre-Carriage by

Place of Receipt

Type of shipment :

by Pre-Carrier

Outright Sale [ ]

Consignment Export [ ]

Vessel/Flight No.

Rotation No.

Others [ ]

(Specify)

Port of Loading

Nature of Contract:CIF[ ]/C&F [ ]/FOB [ ]

Other (Specify) [ ]

Port of Discharge

Country of Destination

Exchange Rate U/S 14 of CA Currency of invoice

S.No

Marks & No. No. & Kind of Pkgs.

Statistical Code & Description of Goods

Quantity

Value FOB

Container Nos.

Net Weight

Gross Weight

Total FOB Value in words

Analysis of Export Value

Currency Amount

Full export value OR where not ascertainable, the

value which exporter expects to receive on the

FOB Value

sale of goods.

Freight

Insurance

Currency

Commission

Rate

Discount

Amount

Other Deductions

Is Export under L/C arrangements? Yes [ ] No [ ]

FOR CUSTOMS

If yes, name of advising bank in India

Customs Assessable value Rs.

(Rupees .

........................................................................................

Bank through which payment is to be received

Export Value Verified

Customs Appraiser

Whether Payment is to be received through the

Date of Shipment

Customs Appraiser

ACU YES/NO

Declaration under Foreign Exchange Regulation Act: 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 above are true and that a)*the value as contracted with the buyer is the same as the full export value declared overleaf/ b) *the full export value of the goods is not ascertainable at the time of export and that the value declared is that which I/We, having regard to the prevailing market-conditions, expect to receive on the sale of goods in the overseas market.

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 I/We further declare that I/We am/are resident in India and I/We have a place of business in India.

I/We* am/are OR am/are not in Caution List of the Reserve Bank of India.

                                                                                                          .........................................................................

Date................                                                                                                 (Signature of Exporter)

@ State appropriate date of delivery which must be the due date for payment or within twelve months [OLD- six months ] from the date of shipment, whichever is earlier, but for exports to warehouses established outside India with the permission of the Reserve Bank of the date of delivery must be within fifteen months.

* Strike out whichever is not applicable

SPACE FOR USE BY RESERVE BANK OF INDIA

Exporter

Invoice No.& Date

SB No.& Date

AR4/AR4A No.& Date

Q/Cert No.& Date

Importer-Exporter Code No.

Consignee

Export Trade Control

If export under:

Deferred Credit [ ]

Joint Ventures [ ]

Rupee Credit [ ]

Others [ ]

RBIs Approval/Cir.No. & Date

Custom House Agent L/C.No.

Pre-Carriage by

Place of Receipt

Type of shipment :

by Pre-Carrier

Outright Sale [ ]

Consignment Export [ ]

Vessel/Flight No.

Rotation No.

Others [ ]

(Specify)

Port of Loading

Nature of Contract:CIF[ ]/C&F [ ]/FOB [ ]

Other (Specify) [ ]

Port of Discharge

Country of Destination

Exchange Rate U/S 14 of CA Currency of invoice

S.No

Marks & No. No. & Kind of Pkgs.

Statistical Code & Description of Goods

Quantity

Value FOB

Container Nos.

Net Weight

Gross Weight

Total FOB Value in words

Analysis of Export Value

Currency Amount

Full export value OR where not ascertainable, the

value which exporter expects to receive on the

FOB Value

sale of goods.

Freight

Insurance

Currency

Commission

Rate

Discount

Amount

Other Deductions

Is Export under L/C arrangements? Yes [ ] No [ ]

FOR CUSTOMS

If yes, name of advising bank in India

Customs Assessable value Rs.

(Rupees .

........................................................................................

Bank through which payment is to be received

Export Value Verified

Customs Appraiser

Whether Payment is to be received through the

Date of Shipment

Customs Appraiser

ACU YES/NO

Declaration under Foreign Exchange Regulation Act: 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 above are true and that a)*the value as contracted with the buyer is the same as the full export value declared overleaf/ b) *the full export value of the goods is not ascertainable at the time of export and that the value declared is that which I/We, having regard to the prevailing market-conditions, expect to receive on the sale of goods in the overseas market.

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.

I/We further declare that I/We am/are resident in India and I/We have a place of business in India.

I/We* am/are OR am/are not in Caution List of the Reserve Bank of India.

......................................

Date................ (Signature of Exporter)

@ State appropriate date of delivery which must be the due date for payment or within twelve months [OLD- six months ] from the date of shipment, whichever is earlier, but for exports to warehouses established outside India with the permission of the Reserve Bank of the date of delivery must be within fifteen months.

* Strike out whichever is not applicable

FOR AUTHORISED DEALERS USE

Uniform Code Number.........................

*Indicate ( ) in the box applicable Date of* (i) negotiation (ii) receipt for collection. Bill No..........................

Type of Bill* (i)DA[ ]/(ii)DP [ ]/(iii)Others [ ]....................(Specify)

Type of shipment:*(i) Firm Sale Contract [ ]/(ii)Consignment Basis [ ]/

(iii)Others [ ] .......................(Specify)

The GR Form was included in the Statement sent to the Reserve Bank with

the R Return for the fortnight ending...........................sent on.......................

We certify and confirm that we have received the total amount of................

(Current amount)

as under being the proceeds of exports declared on this form.

Date of receipt

Currency

Credit to Nostro Account in-------------------Country

Debit to NR Rupee Account of a Bank in -------------Country

Period of R Return with which the realisation has been reported to RBI

In our name

In the name of----------------------------------

Held with us

Held with-----------------------

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(Write the name of the concerned Indian Authorised Dealer Branch. ) Any other manner of receipt (Specify).................................................................................................................................................................................................

.......................................................................

SPACE FOR USE BY RESERVE BANK OF INDIA