Annexure - B - [See rule 13] - Customs Tariff (Determination of Origin of Products under the Duty Free Tariff Preference Scheme for Least Developed Countries) Rules, 2015

Annexure - B [See rule 13] 1. Name and Address of the Exporter /Manufacturer: 2. Registration Number: 3. Country of origin: All cost and price figures are to be shown in US dollars ($) 4. Export Product-wise general information: S. No. Description of the product Model/Brand HS code FOB / ex-works value 5. Product -wise material cost information (to be furnished for each product listed in Para 4 above): A B C D E F G H Sl. no. Description of component, materials, inputs, parts or produce Quantity and Unit Unit Value Total Value HS Code (at six digit level) Supplier‟s name and address Country of Origin of the component, materials, inputs, parts or produce In column H, the entry shall be made to indicate the Country of Origin in terms of the Customs Tariff (Determination of Origin of Products under the Duty Free Tariff Preference Scheme for Least Developed Countries) Rules, 2015 as one of the following:- (i) India; (ii) the beneficiary country of the issuing authority; (iii) non-originating materials used in production. 6. Calculation (i) Value of non-originating materials used in production as a percentage of FOB/ ex-works value:____ (ii) Value of originating materials as a percentage of FOB/ ex-works value:_____ DECLARATION I declare that the information provided by me as above is true and correct. I will permit, as and when required, inspection of our factory/products and undertake to maintain up to date costing records. Signature, Name and Designation of the signatory FOR OFFICIAL USE The particulars given above have been checked, verified by the records maintained by the applicant and found to be correct .On the strength of this evidence, the applicant is eligible to claim that the products have originated from ____________ as shown in serial number 3 above in terms of the provisions of Customs Tariff (Determination of Origin of Products under the Duty Free Tariff Preference Scheme for Least Developed Countries) Rules, 2015. Place and Date: Signature and Name of the Competent Authority with Official Seal