Page 1 of 2 Name of Assessee: M/s. Address . Registration No. SZDFDSGVFDG SL Date of Descriptio Tarrif Quantity Identi No.

. Issue n of Classificat Remove ficatio Goods ion d n chapter marks heading / . If sub any Heading ANNEXURE-IV Removal of Inputs or partally Processed Goods Under Rule 4(5)(a)of the cenvat Credit Rules,2004 (To be maintained by assessee who sends inputs / partally processed goods) Qty of finished goods cleared by job worker Differenc e between Col.5& 12 Quantity of waste material received back / cleared by Job Worker 14 Invoice No. & date ARE-1 No. & Date Partic ulars of paym ent of duty Date of export if the finished goods are cleared fro exports 16 17

Stock Register of goods sent for Job - Work

1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

2 12/21/2008 12/21/2008 12/21/2008 12/21/2008

3 S.S.Ingot S.S.Ingot S.S.Ingot S.S.Ingot

4 72181000 72181000 72181000 72181000

5 15000 1520 14500 13500

Premises/ Challan No. Nature Initial of Date of Factory to which Date of Assessee Clearance removed Prosess of ing finished goods from premises of job worker 6 7 8 9 10 11 XYX LTD 12/12.12.08 Rolling 12.12.08 XYX LTD 12/12.12.08 Rolling XYX LTD 12/12.12.08 Rolling XYX LTD 12/12.12.08 Rolling

12 14570

13 430 1520 14500 13500

15

Page 2 of 2

RE-IV

Initi Rem al of arks asse ssee

18

19