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-section (2) of section 27 of the Act, including documents 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 same Import/Export document (Bill of Entry, Shipping Bill etc.). If yes, give details.

: Yes/No

12.

Whether personal hearing required or not before the case is decided

: Yes/No

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 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

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 marring on.............................. admitted for examination vide Customs Refund Registration No.......................dated........................

for Assistant Commissioner of Customs

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

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 2(3)]

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............................