ANF 5B

Statement of Export for Redemption of EPCG/ Annual EPCG Authorization

Part A

1.	Applicant Details		
IEC Number		Branch Code		
Name			
Address				
Telephone No				
Email  ID				

2. Application Details

Application For		
Ecom. Reference No		Submission Date		
Submitted To		
RLA File No		RLA File Date		

3.	RCMC Details i. RCMC Number ii. Date of Issue 

iii. Issuing Authority iv. valid upto 

Products for which registered 

4.	Type of Exporter (please tick) ( √ ) 

i.	Government Undertaking 

ii.	Public Limited 

iii.	Private Limited 

iv.	Proprietorship 

v.	Partnership 

vi.	Others 

5. Nature of Concern (please tick) ( √ )

i.	Merchant Exporter 

ii.	Manufacturer Exporter 

iii.	Service Provider 

iv.	Others (please specify) 

v.	Merchant cum Manufacturer 

6. Industrial Registration Details

i.	SSI / IEM / LOI or IL Registration Number 

ii.	Date of Issue 

iii.	Issuing Authority 

iv.	Products for which registered 

7. Excise Details (For those registered with Central Excise Authority)

i.	Excise Registration Number 

ii.	Issuing Authority 

557

8. Status House Details:

i.	EH / SEH / TH / STH / PTH 

ii.	Certificate Number 

iii.	Date of Issue 

iv.	Issuing Authority 

v.	Valid Upto 

Part B

9.	EPCG Authorisation Number & date	Actual duty saved amount	

10.      Export obligation period (EOP)

i.	Original date 

ii.	Extended EOP date 

iii.	Actual EO Completion date: 

11.	Installation certificate No. & Date 

12.	Export Product Details: 

i.	Same / similar product name & ITC(HS) code. 

ii.	Alternate Product name & ITC(HS) code. 

13.   Export Obligation (EO) imposed	EO as per actual duty saved amount/ Average	
		EO		
				
In Indian Rs.	In US$	In Indian Rs.	In US$	

+ In case of alternate product export of average EO of alternate product should be given.

14.Details of physical exports/deemed exports made/services rendered for maintaining specific EO of
Authorization for which this redemption is sought

S	Products		Shipping Bill/	FOB / FOR value(in FFE) ++						
No	Exported/		Voucher/Invoice/										
	Supplied/Services		CT 3 / ARE 3/										
	rendered		Lorry Receipt/										
	ITC(HS) Code.		Railway Receipt										
			Details +											
	Same		No			Date	Direct		Third	Deemed	By Group	Other		Total		
	Product/Services						exports		Party	Exports	Company	R&D				
	------------------								exports			Services				
	Alternative											/				
	Product  /											Royalty				
	Services															

+ not to be filled in by hotel industry

++ Only Exports/ Supplies made/ capable of being made/ services rendered out of capital goods imported under the Authorisation for discharge of export obligation imposed on the Authorisation and export proceeds realized to be included.

558

15. We further declare that we have made exports as under for maintenance of Average export obligation (other than that mentioned in 7 above) Exports.

(As per suggestion

FINANCIAL YEAR	TOTAL	VALUE	OF	EXPORTS	DETAILS      OF      SHIPPING      BILLS      FOR	
	(OTHER	THAN	EXPORTS   UNDER	FULFILLMENT	OF	AVERAGE	EXPORT	
	SPECIFIC EO)  INR		OBLIGATION.				

Ø  This column does not include exports covered under Sr. No.7 above.

2.	this column does not include exports rendered for maintaining specific EO of other EPCG authorizations. 

DECLARATION/UNDERTAKING

1.	I/We hereby declare that the particulars and the statements made in this application are true and correct to the best of my/our knowledge and belief and nothing has been concealed or held there from and if found incorrect or false will render me/us liable for any penal action or other consequences as may be prescribed in law or otherwise warranted. 
2.	I/ We hereby declare that I/we have perused the list of SCOMET items as contained in the Appendix 3 to the Schedule 2 of the ITC (HS) Classifications of Export-Import Items, 2009-14 and that the item(s) exported / proposed to be exported does not fall within this list and that I/ We agree to abide by the provisions of the Policy for export of SCOMET items contained in the Foreign Trade Policy, Schedule 2 of ITC (HS) and the Handbook of Procedures (Vol.1), irrespective of the scheme under which the item is exported / proposed to be exported (the underlined portion will be deleted in case an application for export license for SCOMET item is being filed). 

3.	I/We hereby declare that exports counted towards Specific Export Obligation against this licence have not been claimed /counted for fulfillment of annual average export performance / specific export obligation against other EPCG Authorization. 
4.	I hereby certify that I am authorized to verify and sign this declaration as per Paragraph 9.9 of the Policy. 

Signature of the Applicant
Place	Name

Date	Designation
Official Address
Residential Address

Email:

Telephone No.(O):

5. It is certified that all physical exports made as shown in item Nos. 7 & 8 above are in freely convertible currency and payment of the same has been realized*.

Signature with Seal of the Chartered Accountant

*     Deleted.

Note: Realization of export proceeds shall not be insisted, if the Reserve Bank of India (RBI) writes off the requirement of realization of export proceeds on merits and the exporter also produces a certificate from the Foreign Mission of India about the fact of non recovery of export proceeds from the buyer. However this would not include self write off cases.

GUIDELINES FOR APPLICANTS

1.	Appendix 26A duly signed by Chartered Accountant must be submitted. 

2.	Each individual page of the application has to be singed by the applicant. 

3.	Application must be accompanied by documents as per above details.