Customs Series Form No.112
ANNEXURE III
1. Exporter
(a) Name
(b) Address
(c) Telephone No.
(d) Name of Clearing Agent.
2. Goods exported
(a) Description
(b) Quantity
(i) Gross
(ii) Net
(c) Marks & No.
(d) Destination
(e) Shipping Bill No. & Date
3. Vessel
(a) Name
(b) Rotation No.
4. Drawback already paid
(a) Amount
(b) Customs House Reference No.
(c) Quantity/Value on which allowed
(d) Rate at which allowed.
5. Drawback now claimed
(a) Amount
(b) Quantity/Value on which allowed
(c) Rate at which claimed.
6. Reason for the supplementary claim.
7. No. of documents enclosed.*
DECLARATION
1. I/We hereby declare that the supplementary claim of drawback is based on the Customs and Central Excise Duties paid on the raw materials used in the manufacture of goods/exported the duties so paid have not been claimed as rebate under the Cetrtral Excise Rules, 1944.
2. I/We hereby declare that the declaration made herein is true and correct.
Signature ____________________
Designation____________________
*Please enclose copy of communication regarding rate of drawback determined under rule 6 or 7, any other document in support of supplementary claim, or other documents as may be prescribed by
I Commissioner of Customs. Please also enclose calculation sheet.