1.

Shipping Bill No. & Date

:

2.

Quantity exported

:

3.

Description of Goods re-exported

:

4.

Date on which goods are entered for export

[Refer section 74(4) of the Customs Act, 1962]

:

5.

Date of examination of export cargo

:

6.

(i)

FOB value of goods

(ii)

Market value of goods

:

7.

Whether used, and if so, for what period

:

8.

Bill of Entry No. & Date or particulars of other prescribed documents against which goods were cleared on importation

:

9.

Port of import

:

10.

Item Imported

:

11.

Total Assessable value of the imported goods

:

12.

Quantity imported

:

13.

Duty paid on imported goods vide Cash No. & Date

:

14.

No. of documents enclosed*

:

15.

Amount of Drawback claimed (enclose calculation sheet)

:

16.

Reasons for re-export

:

17.

Name and address of Customs House Agent

:

* Refer rule 5 of Re-export of Imported Goods (Drawback of Customs Duties) Rules, 1995.

Name________________________________

Address______________________________

Signatures____________________________

Seal of the Exporter claimant.