Customs Series Form No.

102
(See regulation 2)
Application for refund of duty/interest
PA!"A
To,
The Assistant / Deputy Commissioner of Customs
ICD, Tuglakabad,
Delhi
We wish to lodge this claim for refund of customs duty i.e. additional duty of customs
leied u/s !"#$ of the Customs Tariff Act, %&'# as per details gien below(
Sl.
No. Particulars emar#s
% Import document ")ill of *ntry$
+,umber and Date
!-#./%% %-.0&.-0%!
!!.&%-! -#.0&.-0%!
!#.%-%! %'.%0.-0%!
!#.//%! %/.%0.-0%!
!'/-#'0 %-.%%.-0%!
!/-%1!% %..%%.-0%!
!/!'%'% %/.%%.-0%!
1%&/.1' -'.%-.-0%!
1!#1!#1 %#.0%.-%1
11-.%'' --.0%.-0%1
11!%//# -!.0%.-0%1
1&/&/0# -1.0!.-0%1
#00/.!0 -#.0!.-0%1
#-01/1' %#.01.-0%1
- Duty deposit reference "T2+. Challan
,o. and date
-00'%0!/%% -%.0&.-0%!
-00'%&1-0- 0#.%0.-0%!
-00'!%1%&% -1.%0.-0%!
-00'!-0!!' -!.%0.-0%!
-00'1&--1# -0.%%.-0%!
-00'#%.'1' -!.%%.-0%!
-00'#100%# %/.%%.-0%!
-00'''%''. !%.%-.-0%!
-00'&!00#1 -!.0%.-0%1
-00'&1./&. -1.0%.-0%1
-00'&.0!!' -'.0%.-0%1
-00/10#/0% -'.0!.-0%1
-00/1--/!! -#.0!.-0%1
-00/#..0#. -%.01.-0%1
! Description of goods 2efer 3AD Co+relation statement
1 ,ame and address of
"a$ Importer

A24A I,T*2,ATI5,A6
76AT ,5 8 -/+A, 9/7, :5C;*T +.,
<I9 <A4=2 >I?A2, :?A3* 8 !, D*6?I + &.
"b$ Customs ?ouse Agent </s A. > 9lobal Corporation ":$ 6td.
-0%, ,ew Delhi ?ouse,
)arakhamba 2oad,
,ew Delhi 8 %%0 00%
"c$ Applicant A24A I,T*2,ATI5,A6
76AT ,5 8 -/+A, 9/7, :5C;*T +.,
<I9 <A4=2 >I?A2, :?A3* 8 !, D*6?I + &.
# 2efund Claim under section -'"%$
"a$/section -'"%$"b$ of the Act.
under section -'"%$"b$
. 9round of claim Cus ,otification %0-/-00',
dt( %1+3ept+0'
' Amount of refund claim
s.$%1&%0'(/"
/ Amount of <odat credit aailed from
the additional duty of customs paid
and now coered by the refund
claim
,I6
&
*nclosures@ "in original$ in support of
refund claim (
"@ :lease put a tick mark " $ against the
document being enclosed$
"a$ 6etter of authorisation from the
importer/buyer in case the applicant is
an agent.

,ot Applicable
"b$ Triplicate copy of )ill of *ntry/:ost
parcel wrapper/3hipping )ill/)aggage
2eceipt or the :urchase Inoice

"c$ Duty Challan/5ther document as

eidence of duty payment

"d$ 3igned working sheet for the

amount of refund claimed

"e$ Customs attested inoice

,ot Applicable
"f$ Customs attested packing 6ist ,ot Applicable
"g$ Documents for establishing the
applicantAs eligibility to receie the
refund amount in terms of the proiso
"i.e 3ales Inoices, Co+relation
certificate and unBust enrichment
to sub+ no section "-$ of section -' of
the Act, including documents C.% for
the purposes of sections -/C and -/D
of the Act.
certificates by Chartered Accountant,
3elf Declaration for unBust
enrichment $
"h$ Contract and :urchase order ,ot Applicable
"i$ <odat credit certificate from
Central *Dcise authorities
,ot Applicable
"B$ 5rder in original /in reision/in
Appeal/any other order
"i.e. )ill of *ntry$
"k$ 3hort deliery certificate from
custodian
,ot Applicable
"l$ 3hort shipment certificate from
supplier ,ot Applicable
"m$ 3urey report ,ot Applicable
"n$ Insurance claim settlement
certificate
,ot Applicable
"o$ Catalogue/technical Write+
up/6iterature ,ot Applicable
"p$ )ills for 7reight/Insurance/5ther
charges
,ot Applicable
"E$ Certificate of origin
,ot Applicable
"r$ Any other document considered
necessary in support of the claim
"specify$

%. 5utput TaD :aid Challan
-. :urchase Inoice
!. )oard 2esolution for AuthoriFed
3ignatory
"s$ Total ,umber of documents
enclosed
%!
%0 Any further details deemed necessary
and releant to the refund claim ,o
%% Whether any other refund claim
filed/pending against the same
Import/*Dport document ")ill of *ntry,
3hipping )ill etc.$. If yes, gie details. 4es/,o
%- Whether personal hearing reEuired or
not before the case is decided
4es/,o
%! "a$ Whether the duty has been paid
under protest 4es/,o
%! "b$ If yes, Customs ?ouse protest
registration ,o.
,ot Applicable
)*C+AA!,-N
I/We M KUMAR in my capacity as authorized signatory of M/s. ARYA
INTERNATIONA here!y dec"are that#
$a% the contents of the refund c"aim as per form a!o&e are true and correct to the !est of
my/our information and !e"ief'
$!% the amount and the ground for (hich this refund c"aim has !een fi"ed has not !een
pre&ious"y c"aimed and paid' and that
$c% the e)cess duty c"aimed as refund has not !een passed on to any other person !y the
importer/!uyer .
*ate+ ,-
th
.eptem!er /0,1 .ignature of the app"icant