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["R"]
["APPENDIX IV"]
[]
["(Declaration to be filed in respect of goods for which drawback under S.S.Nos. "]
[]
["03.01,03.02, 04.01, 04.02, 04.03, 07.01, 07.02, 07.03, 08.01,08.02, 08.03, 09.01, 09.02, 09.03, 16,01 16.02, 16.03, 1,7.01, 17.02, 17.03, 18.01, 18.02, 18.03. 19.'01, 19.02, 19 . 03 ,20.01 20.02 , 20.03, 20.06, 20.07, 20.10, 20.11, 20.12, 20.15, 20.16, 20.17, 21.01, 21.02, 21.03, 39..01, 39.03, 39.05, 39.06, 39.07, 39.09, 39.11, 39.12, 39.13, 39.14, 39.15, ,39.16, 3,9.18, 39.19, 39.20, 39.24, 39.25, 39.27, 39.29, 40.06, 42.01, 42.02, 42.05, 42.06, 42.07, 42.10, 42.12, 42.14, 52,.01, 52.03, 52.04, 52.05, 54.03, 54.04 54.05, 54.06, 55.01, 55.02, 55:03, 55.04, 55.05, 56,04, 58.01, 58.02, 58.03, 58.04, 60.06, 60.10, 61.02, 61.05, 61.07 62.02, 62.09, 62.10, 62.21, 63.03, 63.04, 63.061, 63.062, 63.07, 63.08, 63.10, 63.11, 64.01, 64.02, 64.03, 64.06, 64.07, 64.08, 64.09, 64.11, 71.02, 71.03, 71.05, 73.03, 73.11, 73.13, 73.15, 73.22, 74.02, 74.04, 74.05, 74.06, 74.07, 74.12, 74.17, 74.19, 74.20, 74.24, 76.03, 76.04, 82.01, 82.03, 82.031, 82.032, 83.07, 84.26, 84.54, 84.58, 85.37, 85.38, 85.39, 85.40, 85.45, 85.120, 85.154, 87.45, 90.07, 94.01, & 95.08 has been claimed)."]
[]
["Shipping Bill Number & Date ....................."]
[]
["I/We__________________________ (Name of the"]
[]
["Exporter) do hereby declare as follows:-"]
[]
["1. That no CENVAT facility has been availed for any of the inputs used in the manufacture of export products; and"]
[]
["2. That the goods are being exported under bond 'or claim for rebate of Central Excise duty and a certificate from concerned Superintendent of Central Excise, incharge of factory of production, to the effect that CENVAT facility has not been availed for the goods under export, is enclosed (Drawback as per schedule is applicable)."]
[]
["(Name, Address & Signature of the Exporter)"]

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