Form ARE. 4
(in triplicate)
(See rule 30A)

Commissionerate………………………..	Original
Division…………………………………	Duplicate
Range……………………………………	Triplicate

Number and date of entry in daily stock account	Number and description of packages	Gross weight of packages	Marks and numbers	Description of goods with Tariff classification	Value for assessment purpose		Duty		Number and date of Invoice Issued	Remarks
					Rate	Amount (Rs.)	Rate	Amount (Rs.)
(1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)	(9)	(10)	(11)

Notes:

1. Where there are different types of duties, separate entries should be made on different horizontal lines and the amount totaled.

2. Value for Assessment purpose is the value as per section 3 or 4 or 4A of the Central Excise Act, 1944.

Declaration

I/We declare the above particulars to be true and correctly stated.

I/We apply for leave to clear the above goods.…………………………
(Signature of the owner or authorized agent)
Place………….
Date ………….

Assessment Memorandum

(To be entered in words and figures)

1. Total number of packages……………….
2. Quantity of goods on which duty is assessed…………..
3. Rate of duty…………..
4. Total duty payable……………..

…………………………
(Signature of Central Excise)
Place………….
Date ………….

Statement of duty paid at..............

Treasury
Sub-Treasury
Bank
Reserve Bank of India

I. For payment in cash
(to be filled the owner or authorized agent)

Name of the person tendering payment	Name and address of the person on whose behalf the amount is tendered	Particulars of payment	Amount(Rs.)	Head of account
(1)	(2)	(3)	(4)	(5)

1.Excise duty on……. (name of commodity)

2. Additional duties of excise under ………….(Act)

Total Rupees (in words)………………………..
Date……………..
Deposit No………
………………………

(Signature of the Tenderer)

(To be filled by the Treasury or Bank)

Received payment of rupees (in words) …………………….

…………………………
(Signature of the Treasurer/Accountant/Treasury Officer/Agent or Manager)
Date………….

II. Payment through Account Current /CENVAT account

Title of Account	Number and Date of Entry	Amount (Rs.)

………………….
(Signature of the owner or authorized agent)
Date………….

(Note:- see Ntf. No.03/2002-CE(N.T.), dt. 22/02/2002 and Ntf. No.30/2001-CE(N.T.), dt. 21/06/2001)

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