(Declaration to be filled in respect of goods for which drawback, under S.S. No.

03.02, 04.02, 04.03, 07.02, 07.03, 08.02, 08.03, 09.02, 09.03, 16.02, 16.03, 17.02, 18.02, 18.03, 19.02, 19.03, 20.02, 20.03, 20.06, 20.07, 20.11, 20.12, 20.16, 20.17, 21.02, 21.03, 39.01, 39.03, 39.05, 39.06, 39.07, 39.09, 39.11, 39.12, 39.13, 39.14, 39.15, 39.17, 39.18, 39.20, 39.24, 42.01, 42.02, 42.05, 42.06, 42.10, 42.12, ,52.01, 52.03, 52.04, 52.05, 54.03, 54.04, 54.06, 55.01, 55.02, 55.03, 55.04, 55.05, 56.04, 58.01, 58.02, 58.03, 58.04, 60.06, 61.02, 61.05, 61.07, 62.02, 62.09, 62.01, 62.21, 63.01, 63.04, 63.06, 63.07, 63.08, 63.10, 63.11, 64.01, 64.02, 64.03, 64.04, 64.06, 64.08, 64.09, 64.11, 71.03, 71.05, 73.03, 73.11, 73.13, 73.15, 73.22, 74.04, 74.05, 74.06, 74.07, 74.12, 74.17, 74.20, 76.03, 76.04, 82.01, 83.07, 84.25, 84.54, 84.58, 85.37, 85.38, 85.40, 85.45, 85.120, 85.154, 87.45
has been claimed)

Shipping Bill No and Date……………………………………………..

I/We ………………………………………………………………………………..(Name of the Exporter ) do hereby declare as follows :-

• 1. That no Mod vat facility has been availed for any of the inputs used in the manufacture of the export products.

OR

• 2. That the goods are being exported under bond or claim for rebate of Central Excise duty and a certificate from concerned Superintendent of Central Excise, in charge of factory of production, to the effect that Mod vat facility has not been availed for the goods under export, is enclosed (drawback as per schedule is applicable).

(Strike out whichever is not applicable)

Name of the Exporter :

Address:

(Signature & Seal of the Exporter)