Notes:

(i)

This form should not be pasted on the parcel

(ii)

This form should be forwarded to the nearest office of the Reserve Bank of India by the Post Office through which the goods have been despatched.

Parcel Receipt No. and date

Name of the Post Office

1.

Exporters name

2.

Importer-Exporter Code No.

3.

Name and address of consignee

4.

Country of destination

5.

Currency of invoice

6.

Customs assessable value (Rupees)

7.

Description of goods

8.

Quantity of goods

Tonne

Kg.

Litre

Cubic

Sq.

Metre

Number

Others

Metre

Metre

(Please

specify)

1

2

3

4

5

6

7

8

(a)

Unit of measure

(Please tick the

appropriate unit)

(b)

Quantity

9.

Analysis of export value

Particulars

Currency

Amount

Full export value

* Discount (Rate )

* Agency Commission (Rate )

(No application for permission for remittance/deduction from the declared value on account of commission and/or discount will be considered by the Reserve Bank or authorised dealer unless these have been declared on this form)

I/We hereby declare that I/We am/are the seller of the goods in respect of which this declaration is made and that the particulars given above are true and that the value as contracted with the buyer is the same as the full export value declared above.

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 not in the Caution List of the Reserve Bank of India.

am/are

* Complete whichever is appropriate.

(For use of Post Office)

(Signature of Exporter)

Signature

Date

Post Office Stamp

Address

Date

SPACE FOR USE BY RESERVE BANK OF INDIA