ANF 5B Statement of Export for Redeemption of EPCG Authorisation 1. IEC Number: 2. Applicant Details i. Name ii. Address 2A. EPCG authorization Details: (1a) EPCG Authorization No. (1b) Date of Issue : (1c) EPCG File No. (2) Export obligation period (EOP): (a) Original date (b) Extended EOP Date: (c) Actual EO Completion Date: (3) Capital Good (CG) particulars: (a) Date of Import of CG: (b) Date of Installation of CG (c) Installation Certificate No. & Date - Issuing Authority: (4) Export Product Details: (a) Same product Name (b) Similar Product Name (c) Alternate Product Name 2B. Export obligation (EO) Imposed EO over complete EOP In Indian Rupees In US$ (a) Average EO (b) Specific EO (on CIF / Duty saved amount) Total EO (a+b) 3. EPCG Authorisations already obtained till date. S. No EPCG Authorisation No and Date Products to be exported/services to be rendered RA which issued Authorisation CIF Value / Duty saved (Rs) Expiry Date of E.O. Period Redeemption Date / Remarks 1 2 3 4 5 6 7 (i) Redeemed cases during the last 4 years (year-wise) Total: (ii) Not redeemed cases Total: 92 3 (Contd.) Sl. No. EPCG Authorization Details & Date Average EO (Over complete EOP) Separate EO on CIF / Duty Saving (Over complete EOP) Total EO Fixed Fulfilled Fixed Fulfilled Fixed Fulfilled 1 2 (as in 3) 8 9 10 11 12 = 8+10 13 = 9+11 (i) Redeemed EPCG Authorization Total (i) (ii) Non-Redeemed EPCG Authorization Total (ii) Grand Total (i + ii) 4A. Details of physical exports / Deemed exports made / services rendered (For same product) Shipping Bill / Voucher / Invoice / CT 3 / ARE 3 / Lorry / Railway Receipt + FOB / FOR Value (in FFE/) ++ Sl. No. No. Date Direct exports Deemed Exports Third Party exports By Group Company Other R&D services / Royalty Total 1 2 3 4 5 6 7 8 9 4B. Details of physical exports / Deemed exports made / services rendered (For Similar product) Shipping Bill / Voucher / Invoice / CT 3 / ARE 3 / Lorry / Railway Receipt + FOB / FOR Value (in FFE/) ++ Sl. No. No. Date Direct exports Deemed Exports Third Party exports By Group Company Other R&D services / Royalty Total 1 2 3 4 5 6 7 8 9 4C. Details of physical exports / Deemed exports made / services rendered (For Alternate product) Shipping Bill / Voucher / Invoice / CT 3 / ARE 3 / Lorry Receipt / Railway Receipt + FOB / FOR Value (in FFE/) Sl. No. No. Date Direct exports Deemed Exports Third Party exports By Group Company Other R&D services / Royalty Total 1 2 3 4 5 6 7 8 9 93 4D. Total Exports = (4A + 4B + 4C) Shipping Bill / Voucher / Invoice / CT 3 / ARE 3 / Lorry / Railway Receipt + FOB / FOR Value (in FFE/) Sl. No. No. Date Direct exports Deemed Exports Third Party exports By Group Company Other R&D services / Royalty Total 1 2 3 4 5 6 7 8 9 + 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 5. Of above Export value, indicate breakup as under: 5A. Towards Average EO of earlier licences. Sl. No. EPCG Authorisation No. & Date Shipping Bill Amount Remarks No. Date In INR In US$ 1 2 3 4 5 6 7 5B. Towards Specific EO (CIF / Duty Saved Basis) of earlier licences. Sl. No. EPCG Authorisation No. & Date Shipping Bill Amount Remarks No. Date In INR In US$ 1 2 3 4 5 6 7 5C. Towards Total EO of earlier licences. Sl. No. EPCG Authorisation No. & Date Shipping Bill Amount Remarks No. Date In INR In US$ 1 2 3 4 5 6 7 5D. Towards average EO of Authorization for which this Redeemption is sought Shipping Bill / Voucher / Invoice / CT 3 / ARE 3 / Lorry / Railway Receipt + FOB / FOR Value (in FFE/) ++ Sl. No. No. Date Direct exports Deemed Exports Third Party exports By Group Company Other R&D services / Royalty Total 1 2 3 4 5 6 7 8 9 94 5E. Towards specific EO of Authorization for which this redeemption is sought: Shipping Bill / Voucher / Invoice / CT 3 / ARE 3 / Lorry / Railway Receipt + FOB / FOR Value (in FFE/) ++ Sl. No. No. Date Direct exports Deemed Exports Third Party exports By Group Company Other R&D services / Royalty Total 1 2 3 4 5 6 7 8 9 5F. Total EO of EPCG Authorization, sought for redemption: Shipping Bill / Voucher / Invoice / CT 3 / ARE 3 / Lorry / Railway Receipt + FOB / FOR Value (in FFE/) ++ Sl. No. No. Date Direct exports Deemed Exports Third Party exports By Group Company Other R&D services / Royalty Total 1 2 3 4 5 6 7 8 9 NB:- Yearwise & Blockwise details may be grouped separately and then added. 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, 2004-09 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 hereby certify that I am authorised to verify and sign this declaration as per Paragraph 9.9 of the Policy. Signature of the Applicant Place Name Date Designation Official Address Telephone Residential Address Email Address 95 4. This is certified that all physical exports made as shown in item No.4 above are in freely convertible currency and payment of the same has been realized. Signature with the seal of the bank Bank Code No. Date: Note: 1. The consolidated statement may be submitted only at the time of seeking redemption of BG/LUT and the statement should be complete in all respects including the information in Sl. 3, 4 and 5 above duly certified by Chartered Accountant as well as by the Bank. GUIDELINES FOR APPLICANTS 1. Two copies of the application must be submitted unless otherwise mentioned. 2. Each individual page of the application has to be signed by the applicant. 3. Application must be accompanied by documents as per details given below: 4. Statement of Export/ 1. a. For Physical Exports: 1. Consolidated statement of exports made or individual statements (bank/authorized dealer wise) duly certified by a Chartered Accountant (as per Appendix 26A) and bank evidencing exports and realisation in freely convertible. However, in case of exports made under an irrevocable letter of credit or a bill of exchange is unconditionally Avalised/ Co- Accepted/Guaranteed by a bank and the same is confirmed by the exporters bank, realization of export proceeds would not be insisted upon provided the final receipts are in free foreign exchange and a confirmation is given by the Bank in this regard. b. For Deemed Exports: 1. Copy of ARO/Back to Back Inland letter of Credit or Advance Authorisation for Intermediate Supplies or Supply invoices or CT 3 / ARE 3 duly certified by the Bond Office of EOU concerned showing that supplies have been received. 2. Evidence of having received the payment through normal banking channel in the form given in Appendix 22B or a self certified copy of payment certificate issued by the Project Authority concerned in the form given in Appendix-22C. c. For Services rendered: 1. Consolidated statement or individual statements (bank/authorised dealer wise) of services rendered as given in sub section XV duly certified by a Chartered Accountant (As per Appendix 26A) and bank/authorized dealer evidencing foreign exchange earning received through normal banking channel. 2. Copy of Installation Certificate of CG. 3. Customs purpose copy of EPCG Authorisation 4. At the time of Redeemption, the Authorisation holder shall also submit certificate from the Independent Chartered Engineer confirming the use of spares so imported under the Scheme in the installed capital goods on the basis of stock & consumption register maintained by Authorisation holder. 96
