Customs Series Form No.109
ANNEXURE II
Proforma for claiming drawback on re-export of duty paid goods under Section 74 of Customs Act, 1962
[Rule 5 of Re-export of Imported Goods (Drawback of Customs Duties) Rules, 1995]
1. Shipping Bill No. & Date:
2. Quantity exported :
3. Description of Goods re-exported :
4. Date on which goods are entered for export: Refer section 74( 4) of the Customs Act,
1962:
5. Date of examination of export cargo:
6. (i) FOB value of goods:
(ii) Market value of goods:
7. Whether used, and if so, for what period:
8. Bill of Entry No. & Date or particulars of other:
prescribed documents against which goods were :
cleared on importation:
9. Port of Import:
10. Item Imported:
11. Total Assessable value of the imported goods:
12. Quantity Imported.:
13. Duty paid on imported goods vide cash no.& Date:
14. No.Of Documents Enclosed:
15. Amount of Drawback claimed (enclosed calculation Sheet):
16. Reasons for re-export:
17. Name and Address of Custom house Agent:
Refer rule 5 of re-export of imported goods (Drawback of customs Duties) Rule,1995.
Name
..
Address
Signatures
..
Seal of Exporter Claimant
.