APPENDIX-2M
Form of Self Declaration for obtaining Duplicate Copy of freely transferable Licences / Authorisations which are lost or misplaced
(as per para 2.23 and 2.24 of HBP)
To
The Regional authority
.....
I/We hereby solemnly affirm and declare that customs purpose copy/exchange purpose copy/both the copies of Licence No. / Authorisation No.___________dated__________ issued to me/us have been lost/ misplaced, without having been registered with any Customs House / after having been registered with _______________ (Customs House) and not utilised at all/ utilised partly.
The total amount for which the Licence / Authorisation was issued is Rs. (figure and words ____________) and USD (figure in words) ……..the total amount for which the duplicate is now required is to cover the balance of Rs.__________ and USD (figure in words) ...............
The said Licence / Authorisation has not been cancelled, pledged, transferred or handed over by me/us or on my behalf to, any other party for any purpose/consideration whatsoever.
I/We request to cancel the original Licence / Authorisation in lieu of which the duplicate copy has been applied for by me/us.
I/We agree and undertake to return the original Licence / Authorisation, if traced later, to the issuing authority for record
Place:
Date: |
Signature of the Applicant
Name
Designation
Official Address
Telephone
Residential Address
Email Address |
Documents to be enclosed with the application form
As per para 2.24 duplicate copy of freely transferable Authorisation may be issued against an application accompanied with following documents:
1. An application with fee equivalent to 10% of duty saved or duty credit (of unutilized balance).
2. A copy of FIR reporting loss.
3. Self- declaration to indemnify revenue loss, which may be caused on account of issue of such duplicate.