Pass Out Document

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Annexure 9
Pass Out Document
[For removal of Liquid gases in terms of rule 8]
Serial No.______________
1. Name & Address of the manufacturer _____________________________________________
2. Registration Number ______________________________________________________________
3. New ECC Number:
4. Range: ________________ Division: _____________ Commissionerate _________________
5. Date of Removal--__________________ Time of Removal_________________
(1) Description of the goods and its Tariff Sub-Heading
(2) Lorry Tanker Registration No.
(3) Gross Weight of the loaded tanker at the time of
Kg. M3
(4) Tare Weight of Lorry Tanker Kg.
(5) Net Weight of goods despatched [(3) – (4)] Kg. M3
6. Duty leviable on the Net Weight of goods despatched (calculated provisionally):Rs.___________________________________________________________________________________ (In words)(Rupees)____________________________________________________________________ Provisional Entry No. in Daily Stock Account____________________________________________
(i) Supply Schedule Sl. No. Name of the Customer Delivery
Note No. Quantity of Goods delivered Time Customer’s Signature
To be filled latest by the next working day of the return of Lorry Tanker in the factory Kg. M3 In Out Invoice No. & date Final Duty Entry No. in Daily Stock Account

1. Quantity of goods returned to factory in lorry tanker Kg. M3
2. Quantity of goods lost in transit & other losses, if any Kg. M3 I/we hereby solemnly declare that information above is true and correct in all respects. Signature of the Registered person or his authorised agent
(iii) Undertaking
I/We am/are taking clearance of the aforesaid goods under special procedure as per Commissioner of Central Excise permission F.No.__________________ dated _______ under a specific condition that any quantity not shown as delivered to the customer/consignees including the quantity attributable to all kinds of losses will be liable to full payment of duty by me/us. Accordingly, I/we hereby undertake that I/we will pay central excise duty on the entire quantity of such unaccounted goods including all types of losses at the highest effective rate prevailing on the date of removal of the consignment.
Signature of the Registered person or his authorised agent


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