AANNEXURE | DECLARATION FORM ORIGINAL, (See Rule 10 of Customs Valuation Rules, 1988) DUPLICATE Note: This declaration shall not be requited for goods imported as passengers’ Baggage, goods imported for personal use upto value of Rs, 1000/-, Samples of no commercial value, or where the goods are subject to spectic rate o duty. _—1,__Importers Name and Adress a 72. Suppliers Name and Aaaress “Z__Name and address ofthe agent, an “@_Descripton af goods: 5__ County of Origin ‘6. Part of Shioment.. 7. AWB/BL Number and date 18. IGM Number and date (Contact Number and Date ‘Natuee of Transaction (Sale, Consignmet, Hire, Git, ete) Invoice Number and Date Invoice valve Terms of paymer ‘Currency of payment Exchange rate “Terme of Delwery Telationship betwoon buyer and soller [Rule 2 (2)) ifrelatog, what isthe basis of deciared value ‘Conditions or Restrictions 20. Valuation Method applicable, (See Rule 4 to 8) Cost and services not included in the invoice valve (Rule 9) (a)_Brokerage and commissions (b) Cost of container (ec) Packaging cost: (d)_Cost of goods and Services supplied by te buyer re} Royalties and licence feos {Value of proceeds which accure to seller Ssseseoees gli EEE —h)_tnsurance = \)_Loading. unloading, handing charges; tn Landing charges - = ita ble Value in £28._Previous imports of indentical similar goods, any : —{a)_Billot Entry Number and Date : ——_“{b) IGM Number and dates ——24._Any other relevant information (Attach separate sheet, it necessary) DECLARATION 1. We heceny declare thatthe information furnished above is true, complete and correct in every respect. 2. (Mle also undertake to bring t the notice of proper office any particulars which subsequently come to my/our knowedge which will have @ bearing on valuation. Place Date ‘Signature of Importer FOR CUSTOMS HOUSE USE 1, Bill of Entry Number and Dato ‘Valuation Method Applied (See Rules 4 to 8) I declared value net accepted, brief reasons : 4. Reterence Number and date of any previous decisions / ruling 5. Value Assessed AO. Assistant Collector ‘le 1. Declaration form dupeatg day signa by he inpone should be aac wih orginal Ao erry 2. Incasa Orern-Orgna!(Spesing Orde league, InpotevCHA ae equated 1 ely wih 30 ays, No roqust on ths account wilbe constoered afte 30 ays,DECLA (To be signed by an Importer ) swith CHA. Ike declare thal the contents of invoice(s) No.(s) dated Ws. of and of other documents relati lo the goods covered by the said invoice(s) and presented herewith are true and correct in every respect. + OR Without CHA. UWe declare that the contents of this bill of entry for goods imported against Bill of Lading No. dated ard in accordance with the invoice No. dated and other documents are true and correct in every respect. WWe declare that |/ We have not received and do not know of any other documents or information showing a different price, value, (including local payments whether as commission or otherwise), quantity or description of the said goods and that if at any time hereafter. / We discover any information showing a different state of facts. 1/ We will Immediately make the same known to the Commissioner of Customs. 1/ We declare that goods covered by the bill of entry have been imported on an out-right purchase / consignment account. 1/We am /are not connected with the suppliers / manufacturers as (@) Agent / Distributors indentor / Branch / Subsidiary / Concessionaire and (b) Collaborator entitled to the use of trade marks, patent or de: (©) Otherwise than as ordinary importers or buyers. \/We declare that the method of invoicing has not changed since the date on which my/our books of accounts and /or agreement with the suppliers were examined previously by Customs House. (s). NB. t Strike out whichever Is Inapplleable. Signature of Importer Manager