ANNEXURE 63

Export - Statement regarding export of excisable goods without payment of duty to be submitted with renewal of UT.1(1) Name of the assessee

(2) Registration No.

(3) Address

(4) Previous UT-1 No. & Date of acceptance / date of expiry

(5) Details of all removal of goods for export under the UT-1 refered above

Sl. No.	ARE 1 No. & Date	Amount of duty involved	Whether POE received? If yes, date of "pass for shipment order"" by Customs	Details of any short shipment of, if any	Duty & interest paid in case of short shipment or where "pass for shipment order" not received without 6 months (St. time limit)
(1)	(2)	(3)	(4)	(5)	(6)

(6) Declaration.

(a) I/We declare that I/ We have compared the above particulars with the records and books of my/our factory and the same are true and correct to the best of my / our knowledge.

(b) I/We have enclosed proof of duty or interest payment where duty & interest was required to be paid [column (6)].

(c) I/We have submitted all documents for acceptance of proof of export to jurisdictional division office, in all cases where goods have been exported / "pass for shipment order" received by me/ us

(d) I/We am/ are authorised to sign the above statement.

Place:
Date:

Name & Signature of the
Assessee / Authorised Signatory