1)  Financial year during which supplies effected ______________

2)  This application is for payments received during the month &
     year (month as indicated in payment certificate).

3)  Whether the application submitted within 6 months of payment receipt month.

4) Supplies covered under this application is against / to

                                                i) ARO
                                                ii) EOU/EPZ/EHTP/STP
(Tick applicable colmn.)

                                                 iii) PROJECTS FUNDED BY AGAINST world Bank
                                                iv) FERTILIZER PLANTS
                                                v) EPCG LICENCE
                                                vi) OTHERS, PLEASE SPECIFY NAME OF PROJECT FUNDED/AIDED

Details of Project authority    i)

                                                ii)
                                                iii)
                                                iv)
                                                v)
                                                etc.

Details of Contract                  i)  No._______________
                                                    date _____________
                                                ii) Description of item                              }
                                                iii) Total quantity/nos.                              }AS PER
                                                iv) Total Value.                                        }CONTRACT
                                                v) Total value supplied so far                    }
                                                including this claim                                   }

Supply Details

i)  Whether Invoice cum Gate Pass is attested by Central  excise authorities.
ii)  Whether the Gate Pass consigned to Project Authority
iii) Total No. of Invoice cum Gate passes================>2 NOS.
iv) Total Value of goods supplied under this claim
v) Total Value of excise duty paid under this claim

Payment Details

i) Total No. of P.O. submitted=========================>ONE
ii) Total amount received as per P.O.                                       }AS PER
iii) Total amount received                                                        }P. ORDER
iv) Whether date of each payment shown in the P.O.                 }ENCLOSED

DBK Details=====================================> N.A.

i) Total amount of DBK Claimed
ii) Whether Claimed at All Industry Rate or on the basis of H.Q. rate fixation letter
iii) Are the supplies under DEEC
iv) Has modvat been availed
v) Whether a copy of DBK schedule showing the All India Industry Rate submitted
vi) In case of DBK fixation provisional 50/75 claimed
 

I hereby declare that above particulars are true and correct.

(To be Signed by (Signature)_____________ the applicant) Name : ________________

(Name of the company / Firm)