Annexure II

Statement containing particulars referred to in item 12 of the application made under section 32E(1) of the Central Excise Act, 1944

1. Details of information which has not been correctly declared in the monthly return :

2. Additional amount of duty payable on the goods covered in the monthly return and the manner in which such duty has been derived :

3. Duty liability accepted out of the total duty demanded in the show cause notice, if any, issued and the manner in which such duty liability has been derived :

4. Full and true disclosure of the facts regarding the issues to be settled including the terms of settlement sought for by the applicant :

Place :

Date :

Signature of the applicant

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