FOR THE MONTH OF _________

Refund on the Bill of Entry No. ____________ Dated __________ permitted to be filed within the maximum time period of one year refundable under Notification No. 102/2007 dated 14/09/2007.

Self-declaration along with the refund claim to the effect that the incidence of 4% CVD has not passed on to any other person in respect of Bill of Entry No. _______________ Dated ________ claiming Refund of Additional Duty (Imports)

This is to declare and certify that the exemption from Additional duty and consequent refund, as contained in the Notification No. 102/2007 dated 14/09/2007, is being claimed and is required to be given effect because the following conditions are stipulated therein are fulfilled in the respect of the Bill of Entry No. _____________ Dated _________ and Challan No. ___________ Dated _____________.

a) We are registered with VAT /CST authorities of Department of Trade & Taxes, Govt. of __________________ under TIN Registration No.______________

b) We, the importer of the said goods have paid all duties, including the said additional duty of Customs leviable thereon, as applicable, at the time of importation of the goods under the said Bill of Entry No. __________________ dated _____________

c) While issuing the invoice for said of the said goods, we, the importer, have specifically indicated in the invoice that in respect of the goods covered therein, no credit of the additional duty of customs levied under Sub-section (5) of Section 3 of the Customs Tariff Act, 1975 shall be admissible to the buyer and a stamp on the invoice (to state that no CENVAT Credit is admissible) for the purpose of para 2(b) of the said notification has been affixed;

d) The details of the sale invoices are given separately.

e) We, the importer have filed the claim for refund of the said additional duty of Customs paid on the importer goods with the jurisdictional Customs Officer, the Dy. Commissioner of Customs, Jawahar Customs House, Sheva, Tal Uran, Dist. Raigad, Navi Mumbai-400 707, the port through which the clearance of gods through Customs was obtained i.e. Nhava Sheva.

f) We, the importer have paid on sale of the said goods, appropriate Sales Tax or Value Added Tax, Inter State Tax/CST, as the case may be and details are given in the attached sheet along with the original of the Challans depositing the Tax and Invoices raised in this regards.

g) We, the importer have provided copies of the following documents along with the refund claim.

i. Original of the Bills of Entry and Challan detailed in attached sheet as the documents evidencing payment of the said additional duty.

ii. Original of he Challans evidencing payment of appropriate Sales Tax/Value Added Tax, Etc, as the case may be, by us the importer, on sale of such imported goods.

The Refund claim in respect of the Bill of Entry No. ___________ Dated __________ as above, is filed on the month of _____________, with the jurisdictional Customs Officer for sanction of the refund claim satisfying that the conditions referred to in Para 2 of the said Notification No. 102/2007 dated 14/09/2007, are fulfilled.



Date: For M/s. ________________________

Signature of the Applicant.

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