ANNEXURE-9

Pass Out Document
[For removal of Liquid gases in terms of rule 8]

Serial No._______________

Original
Duplicate
Triplicate

1. Name & Address of the manufacturer _____________________________________________

2. Registration Number ______________________________________________________________

3. New ECC Number: ccccccccccccccc

4. Range: ________________ Division: _____________ Commissionerate _________________

5. Date of Removal--__________________ Time of Removal_________________
Part-I

(1) Description of the goods and its Tariff Sub-Heading No.
(2) Lorry Tanker Registration No.
(3) Gross Weight of the loaded tanker at the time of despatch	Kg.                      M3
(4) Tare Weight of Lorry Tanker	Kg.
(5) Net Weight of goods despatched [(3) – (4)]	Kg.                      M3

6. Duty leviable on the Net Weight of goods despatched (calculated provisionally):
Rs._____________________________________________________________________________
(In words)(Rupees)________________________________________________________________
Provisional Entry No. in Daily Stock Account____________________________________________
Part-II
(i) Supply Schedule

Sl. No.	Name of the Customer	Delivery Note No.	Quantity of Goods delivered	Time		Customer’s Signature	To be filled latest by the next working day of the return of Lorry Tanker in the factory
			Kg.       M3	In	Out		Invoice No. & date	Final Duty	Entry No. in Daily Stock Account
1.
2.
3.
4.
5.

(ii)

1.	Quantity of goods returned to factory in lorry tanker	Kg.               M3
2.	Quantity of goods lost in transit & other losses, if any	Kg.               M3

I/we hereby solemnly declare that information above is true and correct in all respects.

Signature of the Registered person or his authorised agent
(iii)Undertaking
I/We am/are taking clearance of the aforesaid goods under special procedure as per Commissioner of Central Excise permission F.No.__________________ dated _______ under a specific condition that any quantity not shown as delivered to the customer/consignees including the quantity attributable to all kinds of losses will be liable to full payment of duty by me/us. Accordingly, I/we hereby undertake that I/we will pay central excise duty on the entire quantity of such unaccounted goods including all types of losses at the highest effective rateprevailing on the date of removal of the consignment.

Place

Date

Signature of the Registered person or his authorised agent

(Back to Part-III of Ch.4)

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