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Application for refund of CENVAT credit under Rule 5 of the CENVAT Credit Rules, 2004
March, 05th 2013
                                              [FORM `A'
                               (See paragraph 3 of the Appendix)

 (Application for refund of CENVAT credit under rule 5 of the CENVAT Credit Rules, 2004)

            (Refund relating to the given period i.e. quarter or month ____________ )


        The Deputy Commissioner/ Assistant Commissioner of Central Excise,


        I/ We have exported, the final products or output services of under mentioned description,
value quantity to ____________ during the given period. I/We am/are not in a position to utilize
the CENVAT credit of duty/service tax taken,-

  (a) on inputs or input services [used in or in relation to] the manufacture of final products
      cleared for export under bond of letter of undertaking;
  (b) on input or input services [used for] providing output services exported without payment of
      service tax,
and such credit being allowed under Rule 3 of the CENVAT Credit Rules, 2004, for payment of
duty in respect of final products cleared for home consumption or for export on payment of duty or
for payment of service tax on output services during the given period. I/We request that refund of
such credit for the given period may be granted. The following particulars / enclosures are being
provided/ enclosed by me/ us for this purpose.

(A)&(B) Omitted by Notification No.7/2010-CE(N.T), dated 27.2.2010


        a. The value of all output services and exempted services provided, including value of
           services exported.
        b. The value of all excisable and non excisable goods cleared, including the value of
           goods exported.
        c. The value of bought out goods sold.


        a. Copy of the relevant Shipping Bills or Bills of Export duly certified by the Officer of
           Customs to the effect that the goods have in fact been exported (in case of final
        b. Copy of invoices.
        c. Certificate from the bank certifying realization of export proceeds (in case of export of
           output services).
        d. Relevant extracts of the records maintained under the Central Excise Rules, 2002,
           the CENVAT Credit Rules, 2004, or the Service Tax Rules, 1994, as the case may
           be, evidencing taking of CENVAT credit, utilization of such credit in payment of
           excise duty or service tax and the balance unutilized credit during the given period.
                   [(DD) The Exporter shall give the details in the following Table:


           Details of goods/services exported on which refund of CENVAT credit is claimed (Rs. In lakh)
S.     Details of shipping bill/Bill of export/export            Details of CENVAT credit on which refund claimed
No.                  documents etc.
(1)                         (2)                                                           (3)
      No    Date       Date      Goods/       Quantity   Invoi    Name       Service         Details of    Service      Date
       .                of       service         and       ce       of         tax/           service/      Tax/        and
                      export exporte          value of    No.,   service      Central          goods       Central    details
                      order          d         goods     date    provider     Excies         provided      Exscis        of
                                             exported     and        /      Regn. No.           with       e duty    paymen
                                               / value   Amo     supplier   of service     classificatio   payabl     t made
                                                  of      unt       of       provider/        n under         e          to
                                              services            goods     supplier of    Finance Act               service
                                             exported                         goods         1994/Centr                    s
                                                                                             al Excise               provider

 Documents attached to            Total export during the        Total domestic clearances        Total amount of CENVAT
evidence of the amount of        period for which refund is      during the period for which         claimed as refund
     service tax paid                     claimed                     refund is claimed
           (4)                               (5)                            (6)                              (7)

         The table shall be certified by a person authorized by the Board of Directors (in the case
of a limited company) or the proprietor or any partner (in case of partnership firm) if the amount of
refund claimed is less than Rs.5 lakh in a quarter. In case the refund claim is in excess of Rs. 5
lakh, the Table shall also be certified by the Chartered Accountant who audits the annual
accounts of the exporter for the purposes of Companies Act, 1956 (1 of 1956) or the Income Tax
Act, 1961), as the case may be.]

                          Rs.(in figures and in words) ___________________________________
I/we opt for/do not opt for the facility of the refund amount being credited directly in my/our bank
account details as furnished below:

         a. Account Number
         b. Name of the Bank
         c.    Branch (with address)

        I/We certify that the aforesaid particulars are correct and I/We am/are the rightful
claimant(s) to the refund of excise duty or service tax, as the case may be, due thereon which
may be allowed in my/our favour.

         I/We declare that no separate claim for rebate of duties or service tax in respect of
excisable materials used in the manufacture of the goods or output service covered by this
application has been or will be made under the Customs and the Central Excise Duties Drawback
Rules, 1971 or under claim for rebate under the Central Excise Rules, 2002 or the Export of
Services Rules, 2005.
       I/We declare that we have not filed/ will not file any other claim for refund under Rule 5 for
the same quarter or month to which this claim relates.

                                                                            Signature and full address of the claimant(s)

Refund Order No. ________________                                   Date _____________

            The claim of Shri/Messrs _____________________ has been scrutinized with the
relevant Shipping Bills or Bills of Export/ Invoices/ Certificate from Bank certifying realization of
export proceeds and refund of Rs._____________ (Rupees_________________ ) is sanctioned.

Date __________
                                                                          Deputy Commissioner/Assistant Commissioner
                                                                                  of Central Excise ________________
Forwarded to :-

d.     The Chief Account Officer, Central Excise, for information and necessary action.
e.     The Commissioner of Central Excise ______________________

Date ____________

                                            Deputy / Assistant Commissioner of Central Excise _____________

        Passed for payment of Rs. ______________ (Rupees __________________________ ).
The amount is adjustable under Head `0038 ­ Union Excise Duties ­ Deducted Refunds/ 0044 ­
Service tax ­ Deduct Refunds'.

Date ____________                                                                               Chief Accounts Officer

      Cheque No. ___________ dated ___________ issued in favour of Shri/ Messrs.
_____________________ for Rs. _________ (Rupees ________________________________ )

Date __________                                                                                 Chief Accounts Officer

Received Cheque No. ____________ dated ___________ for Rs. ___________ (Rupees _____
______________________ )

Dated _____________                                                                               Signature of claimant.]

1 Vide Annexure to Notification No. 5/2006-C.E.(N.T.), dated 14-3-2006.
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