Annexure – I
| 1. Applicant Details |
| i. Name |
| ii. IEC No |
| iii. Address |
| 2. Type of Exporter (please tick) |
| i. Merchant Exporter |
| ii. Manufacturer Exporter |
| iii. Service Provider |
| iv. Others( please specify) |
| v. Merchant cum Manufacturer |
| 3. RCMC Details |
| i. RCMC Number |
| ii. Date of Issue and valid upto |
| iii. Issuing Authority |
| iv. Products for which registered |
| 4. Industrial Registration Details |
| i. SSI / IEM/LOI or IL Registration Number |
| ii. Date of Issue |
| iii. Issuing Authority |
| iv. Products for which registered |
| 5. Service Tax Registration Details ( In case of Service providers registered with Service Tax authorities) |
| i. Service Tax Registration Number |
| ii. Issuing Authority |
| iii. Services for which registered |
| 6. Status House Details |
| i. EH/SEH/TH/STH/PTH |
| ii. Certificate Number |
| iii. Date of Issue and valid upto |
| iv. Issuing Authority |
| 7. Excise Details (For those registered with Central Excise Authority ) |
| i. Excise Registration Nimber |
| ii. Date of Issue / Issuing Authority |
| 8. Application Fee Details |
| Amount (Rs) |
| Electronic Fund Transfer No. |
| 9. Sector Classification of Capital Goods sought to be imported under the Scheme (Please tick) |
| i. Industrial sector |
| ii. Agricultural sector |
| iii. Service sector |
| 10. Products to be exported/services to be rendered. | ITC (HS) CODE |
| Sr No | EPCG Authorisation No | EPCG Authorisation Date | CIF Value / duty saved | E.O. fixed in freely convertible currency | Percentage of E.O. fulfilled | Expiry date of E.O. period |
| Sl. No. | Financial Year | Total FOB Value of exports/ services rendered for the same/similar product /service(Rs in Crores) |
| 1 | 2 | 3 |
| 1. | ||
| 2. | ||
| 3. | ||
| Total | ||
| Average export performance |
| S.No | Authorisation No and Date | RA which issued Authorisation | CIF/ Duty Saved Value (Rs) | EO fixed on duty saved amount (in freely convertible currency)/INR | Specific EO fulfilled on duty saved amount (Rs) | Annual Average EO Fixed (Rs.) | Average EO due till last financial year (Rs) | Average EO fulfilled till last financial year (Rs) | Expiry Date of EO period |
| S No | Description of the items of import | ITC(HS) Code | Nature of Capital Goods sought to be imported + | Quantity | Primary Use of Capital Goods sought to be imported ++ |
| S No | Description of the items of import | ITC(HS) Code | Nature of Capital Goods sought to be imported + | Primary Use of Capital Goods sought to be imported ++ |
| Technical Specifications/ Model No. etc | Quantity | CIF Value in freely convertible currency |
| Total effective Customs duty on items to be imported/deemed to be imported (in %) + | Duty to be levied under the Scheme (in %) | Duty Saved (in %) | CIF Value of imports/deemed imports (in Rs) | Duty saved (in Rs) |
| 1 | 2 | 3 = 1 - 2 | 4 | 5 = 3 * 4 / 100 |
| Total duty saved (Rs.) as per column no.5 at S.No.15. | Export Obligation (as a multiple of duty saved) to be imposed | Average Export Obligation to be imposed | Export obligation period to be imposed (in years) | |||||
| 6 times ++ | 8 times | 8 years | 12 years +++ | |||||
| (Rs.) | (USD) | (Rs.) | (USD) | (Rs.) | (USD) | (indicate specifically) | ||
| 18. Port of Registration (for the purpose of imports): |
| 19. Address of the factory/premises of the applicant where the capital goods to be imported are proposed to be installed |
| i. Name of the supporting manufacturer |
| ii. Address of the supporting manufacturer |
| iii. SSI/LOI/IL regn. no. and date |
| iv. Products endorsed on SSI/IL/IEM |
| v. Excise Registration No. And issuing authority. ( if applicable) :- |
Annexure – II
| 1. Applicant Details |
| Name & address |
| 2. EPCG Authorisation Number & date | Actual duty saved amount |
| 3. Export obligation period (EOP) | |
| i. Original date | |
| ii. Extended EOP date | |
| iii. Actual EO Completion date: | |
| 4. Installation certificate No. & Date | |
| 5. Export Product Details: | |
| i. Same / similar product name & ITC(HS) code. | |
| ii. Alternate Product name & ITC(HS) code. | |
| 6. Export Obligation (EO) imposed | EO as per actual duty saved amount/ Average EO | ||
| In Indian Rs. | In US$ | In Indian Rs. | In US$ |
| 7. Details of physical exports/deemed exports made/services rendered for maintaining specific EO of Authorization for which this redemption is sought | |||||||||
| S No | Products Exported/ Supplied/Services rendered ITC(HS) Code. | Shipping Bill/ Voucher/Invoice/ CT 3 / ARE 3/ Lorry Receipt/ Railway Receipt Details + | FOB / FOR value(in FFE) ++ | ||||||
| Same Product/Services ------------------ Alternative Product / Services | No | Date | Direct exports | Third Party exports | Deemed Exports | By Group Company | Other R&D Services / Royalty | Total | |
| FINANCIAL YEAR | TOTAL VALUE OF EXPORTS (OTHER THAN EXPORTS UNDER SPECIFIC EO) INR | DETAILS OF SHIPPING BILLS FOR FULFILLMENT OF AVERAGE EXPORT OBLIGATION. |
| Signature of the Applicant Name Designation Official Address Telephone Residential Address Email Address |
Place Date |
Signature with Seal of the Chartered Accountant
Annexure – III
| Financial Year 1. 2. 3. |
FOB Value US$ Rs. US$ Rs. US$ Rs. |
(Signature and Stamp/ Seal of the Signatory)
(Chartered Accountant/ Cost & Works Accountant/Company Secretary)
Place: Date: |
Name of the Signatory: Address: Membership No: |
Annexure – IV
| Place: Date: |
(Signature and Stamp/ Seal of the Signatory) (Chartered Accountant/ Cost & Works Accountant Name of the Signatory: Address: Membership No: |
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