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1. General Information: Customs Security No.: Form No: Nature of Cargo: [ ] Government [ ] Non-Government Shipping Bill No. & Date: Mode of Transport: [ ] Air [ ] Land [ ] Sea [ ] Post/Couriers [ ] others Category of Exporter: [ ] Custom (DTA units) [ ] SEZ [ ] Status holder exporters [ ] 100% EOU [ ] Warehouse export [ ] others (Specify)....... RBI approval no. & date, if any: IE Code: AD code: Exporters Name & Address: AD Name & Address: Consignee’s Name & Address: Mode of Realisation : [ ] L/C [ ] BG [ ] Others (advance payment, etc. including transfer/remittance to bank account maintained overseas ) Port of Loading / Source Port in case of SEZ : Third Party name & Address ( In case of third Party Payments for Exports) Country of Destination: Port of Discharge: Name of the Indian bank and AD code, in case of LC/BG Whether payment to be Received through ACU? [ ] Yes [ ] No Let Export order (LEO) Date: General Commodity Description: State of Origin of Goods: Total FOB value in words (INR): Custom Assessable value (INR)*:


2. Invoice –Wise details of Export Value ( If more than one invoice for a particular shipping bill , the block 2 will repeat as many times of invoices)
Invoice No. Invoice date. Invoice Currency: Invoice Amount: Nature of Contract: [ ] FOB [ ] CIF [ ] C&F [ ] CI [ ] Others Particulars Currency Amount in FC Exchange Rate Amount (INR) FOB Value Freight Insurance Commission Discount Other Deduction Packing Charges Net Realisable value EXPORT DECLARATION FORM
3. Applicable for Export under FPO/Couriers Name of the post Office: Number & date of Parcel receipts : Stamp & Signature of Authorised Dealer
4. Declaration by the Exporters (All types of exports)
I /We hereby declare that I/we @am/are the seller/consignor of the goods in respect of which this declaration is made and that the particulars given above are true and that the value to be received from the buyer/third party represents the export value contracted and declared above. I/We undertake that I/we will deliver to the authorised dealer bank named above the foreign exchange representing the full value of the goods exported as above on or before........................ (i.e. within the period of realisation stipulated by RBI from time to time ) in the manner specified in the Regulations made under the Foreign Exchange Management Act, 1999.
I/We @ am/are not in the Caution List of the Reserve Bank of India. Dat Date: (Signature of Exporter)
5. Space for use of the competent authority (i.e. Custom/SEZ) on behalf of Ministry concerned: Certified, on the basis of above declaration by the Custom/SEZ unit, that the Goods described above and the export value declared by the exporter in this form is as per the corresponding invoice/gist of invoices submitted and declared by the Unit.
(Signature of Designated/Authorised officials of Custom /SEZ ) @ Strike out whichever is not applicable. * Unit declared Value in case of exports affected from SEZs


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