Customs Series Form No. 111
ANNEXURE-II
Form for claim of drawback under Rule 13
Customs Form No...................
To,
The Asstt. Commissioner of Customs,
Drawback Department,
(Name & Address of the Custom House)
Sub: Drawback claim under Sec. 75 of the Customs
Act, 1962
We wish to lodge this claim for Drawback of duty of Customs as per the details below together with copies of all the relevant documents :
1. Shipping Bill No. & date
2. Invoice No. & date
3. Bill of Lading or Airway Bill No. &
date
4. Description and quantity of goods
exported
5. Drawback sub-serial No.
6. F.O.B. value& present market value
of goods
7. Calculation of drawback claim
(worksheet attached) : 1
8. Indicate whether the claim is as per
brand rate
9. Brand rate letter No. & date and its
validity period
10. Indicate particulars of Test report
& Test bond (wherever necessary)
I.............., the applicant representing the exporter do hereby declare that what is stated above is true to the best of my information and belief, I also declare that no drawback has been claimed earlier pertaining to and Shipping Bill No............... dated..................
(Signature of the Applicant)
*Please attach a list of documents enclosed. Refer Rule 13 of Customs and Central Excise Duties Drawback Rules,1995