Customs Series Form No.102

(See regulation 2)

Application for refund of duty/interest

PART-A



To,
The Assistant Commissioner of Customs,
.........................

I/We wish to lodge this claim for refund of customs duty/interest which have been paid in excess by me/us as per details given below:

	1.    Import/Export document (Bill of Entry, Shipping Bill 
	      etc.)/Purchase Invoice -Number and Date                     	: 


	2.    Duty deposit reference (Cash No./Deposit No.) and date      	: 

 
	3.    Description of goods                                        		: 


	4.    Name and address of	(a) Importer                         	: 

				(b) Customs House Agent              	: 

                             		(c) Applicant                        	: 



	5.    Refund Claim under   : section 27(1)(a)/section
 
	      27(1)(b) of the Act.                                    



	6.    Ground of claim*     					: 

	      [*specify with details whether the claim is on account of reassessment of rates of 

	      duty/valuation, Shortage/Short-landing, Pilferage, appellate order, arithmetical/clerical
 
	      error, any other ground (specify).] 
 


	7.    Amount of refund claim                                      		: 


	
	8.    Amount of Modvat credit availed from the additional
	      duty	of customs paid and now covered by the refund claim    	: 

 
	
	9.    Enclosures* (in original) in support of refund claim 	:
 

	      (*Please put a tick mark ( ) against the document being enclosed)  

		(a) Letter of authorisation from the importer/buyer in
	          	     case the applicant is an agent.  

		(b) Triplicate copy of Bill of Entry/Post parcel wrapper/
		     Shipping Bill/Baggage Receipt or the Purchase Invoice  

		(c) Duty Challan/Other document as evidence of duty
          		     payment  

      		(d) Signed working sheet for the amount of refund claimed  

      		(e) Customs attested invoice  

      		(f) Customs attested packing List  

      		(g) Documents for establishing the applicant"s eligibility to receive the refund amount
          		     in terms of the proviso to sub- no section (2) of section 27 of the Act, including
          		     documents ;.1 for the purposes of sections 28C and 28D of the Act.

      		(h) Contract and Purchase order  

      		(i) Modvat credit certificate from Central Excise authorities  

      		(j) Order in original /in revision/in Appeal/any other order  

      		(k) Short delivery certificate from custodian  

      		(l) Short shipment certificate from supplier  

      		(m) Survey report  

      		(n) Insurance claim settlement certificate  

      		(o) Catalogue/technical Write- up/Literature  

      		(p) Bills for Freight/Insurance/Other charges  

     	 	(q) Certificate of origin  

      		(r) Any other document considered necessary in support  

          		    of the claim (specify)  

     	 	(s) Total Number of documents enclosed		:  
 


	10.   Any further details deemed necessary and relevant to the	:
      	       refund claim  



	11.   Whether any other refund claim filed/pending against the	:	Yes/No
	       same Import/Export document (Bill of Entry, Shipping
      	       Bill etc.). If yes, give details.  



	12.   Whether personal hearing required or not before the case	:	Yes/No
      	       is decided  



	13.   	(a) Whether the duty has been paid under protest	:	Yes/No
      		(b) If yes, Customs House protest registration No.  

DECLARATION

I/We....................................................................... hereby declare that -

(a) the contents of the refund claim as per form above are true and correct to the best of my/our information and belief;

(b) the amount and the ground for which this refund claim has been filed has not been previously claimed and paid; and that

(c) the excess duty claimed as refund has not been passed on to any other person by the importer/buyer .

Signature of the applicant

Date................

PART B
[See regulation 2(2)]
ACKNOWLEDGEMENT
FOR CUSTOM HOUSE USE

Refund claim of Mr./M/s...................... for Rs............. against Bill of Entry/Post Parcel/ Baggage Form/Shipping Bill No...... dated ..........received in complete, manner on.....admitted for examination vide Customs Refund Registration No............. dated:...........

for Assistant Commissioner of Customs

Dated.......

ACKNOWLEDGEMENT
TO BE ISSUED TO THE APPLICANT

FILE NO..........

Refund claim of Mr./M/s for........ Rs ..........against Bill of Entry/Post Parcel/Baggage Form/Shipping Bill No...... dated........... received in complete manner on admitted for examination vide Customs Refund Registration No.............. dated................

for Assistant Commissioner of Customs

Date...............

PART C
[See regulation ]
CLAIM SCRUTINY
FOR CUSTOM HOUSE USE

FILE NO................

Refund claim of Mr/M/s for........ Rs.......... against Bill of Entry/Post Parcel/Baggage Form/Shipping Bill No............. Dated........... has been scrutinised and found deficient in the following manner for purpose of examination under section 27 of the Customs Act, 1962. Importer/Customs House Agent/Applicant is requested to make good the deficiency and resubmit the claim at the earliest.

1.
2.
...

Proper Officer of Customs

Date.........

---

TO BE ISSUED TO THE APPLICANT

FILE NO ...............

Refund claim of Mr./M/s for........... Rs........... against Bill of Entry/Post Parcel/Baggage Form/Shipping Bill No....... dated........... has been scrutinised and found deficient in the following manner for purpose of examination under section 27 of the Customs Act, 1962. Importer/Customs House Agent/ Applicant is requested to make good the deficiency and resubmit the claim at the earliest.

1.
2.

Proper Officer Of Customs

Date............