NOTE : PLEASE SEE PARAGRAPH 6.12 AND 6.13 OF THIS HANDBOOK

a)	Name & address of the Licence holder			:		

b)	EPCG Licence No. & Date				:
c)	C.I.F. Value					:	(i)Issued
							:	(ii)Utilised

d)	Export Obligation imposed on the EPCG Licence 
	i)  Export obligation equal to four/five/six 
	    times of the CIF value of capital goods.		:
	ii) Average exports to be maintained			:

e)	Product to be exported/type of service rendered	: 
	as per the conditions attached to the 
	EPCG licence.

f)	Date of clearance of the first consignment of		: 
	C.G. under the EPCG Licence from the customs 
	authorities / Date of receipt of CG from indigenous 
	source

g)	Date of completion of export obligation		:

h)	Details of Exports					:
	i)   Year / Block of year from the date of		:
	     issue of licence
	ii)  Proportion of total Export Obligation		:	
	     fulfilled
	iii) Details					:

S.No.	Product Exported/service rendered	Shipping Bill No./ Date Date of L/C/ ARO	FOB value of exports			Remarks
			Exports made out of imported capital goods to discharge E.O. imposed on the Licence and export proceeds realised	Exports made for maintaining average export performance and export proceeds realised	Exports through third Party as per S/Bill and export proceeds realised
(1)	(2)	(3)	(4a)	(4b)	(4c)	(5)

We hereby declare that the above particulars are correct

______________________-____________________
Signature with seal and Designation of the exporter

It is certified that we have verified the books of accounts Books of the above exporter and the particulars given above in respect of export both physical and deemed, are correct. It is also certified that all the shipping bills verified by me / us contained the EPCG Licence No. and Date as given at Sl. No. b) above.

__________________________________________________
Signature with seal and of the Chartered Accountant / Cost
& Work Accountant
Membership No.

This is certified that all physical exports as shown above in are in freely convertible currency and payment of the same has been realised.

___________________________________________________
Signature with the seal of the Bank
Bank Code No. _____________________________________

Date:

Note:

1. The consolidated statement may be submitted only at the time of seeking redemption of Bank Guarantee / Legal Undertaking and the statement should be complete in all respects including the information in S. No. (3) column (4) above duly certified by Chartered Accountant as well as by the Bank.

_____________________________________________________________________________________________

Documents to be enclosed with the application form 

1) Copy of bill of entry showing the date of clearance of the first consignment;

2) Import Licence in original along with its enclosures.