Port Code SB No SB Date

INDIAN CUSTOMS EDI SYSTEM INDEL4 6011884 29-NOV-24

CENTRAL BOARD OF INDIRECT TAXES AND CUSTOMS IEC/Br FUEPS1726J 0
DEPARTMENT OF REVENUE - MINISTRY OF FINANCE GSTIN/TYPE 07FUEPS1726J1ZB GSN
GOVERNMENT OF INDIA CB CODE AAACC6689ECH001
TYPE INV ITEM CONT
Nos 1 1 0
NEW CUSTOM HOUSE, IGI AIRPORT, NEW DELHI - 110037 PKG 3 G.WT KGS 213 * SB22291120242213

PART - I - SHIPPING BILL SUMMARY

1.MODE 2.ASSESS 3.EXMN 4.JOBBING 5.MEIS 6.DBK 7.RODTP 8.LICENCE 9.DFRC 10.RE-EXP 11.LUT
STATUS

AIR N Y N N N Y N N Y
A

12.PORT OF LOADING INDEL4 (Delhi) 13.COUNTRY OF FINALDESTINATION ANGOLA

14.STATE OF ORIGIN Delhi 15.PORT OF FINAL DESTINATION LAD (LUANDA - )

PY
16.PORT OF DISCHARGELAD (LUANDA - ) 17.COUNTRY OF DISCHARGE ANGOLA
1.EXPORTER'S NAME & ADDRESS 7.CONSIGNEE NAME & ADDRESS
DRx Laboratories India Inc FREEMED LDA
B DECLARAN

SHOP NO - 201, PLOT NO 4, SECOND FL RUA PRINCIPAL DO PATRIOTA, LUANDA

DETAILS

LOCAL SHOPPING CENTER, ANGOLA, 06022 CTC : FRED YARIK GREGORIO ALFREDO

CO
VIKAS PURI 2.Type Private AO
3. AD CODE: 6360077 8. GSTIN / TYPE 07FUEPS1726J1ZB GSN
4.RBI WAIVER NO.& DT 9.FOREX BANK A/C NO. 92XXXXXXXXXX515
5.CB NAME COMMITTED CARGO CARE LTD 10.DBK BANK A/C NO.
6.AEO 11. IFSC NO.
1.FOB VALUE 2.FREIGHT 3.INSURANC 4.DISCOU 5.COM 1.DBK CLAIM 2. IGST AMT 3.CESS AMT
SUMMA
E MANIFEST C.VALU

EX.PR.
937280 300000 0 0 0 0

D.
6.DEDUCTIONS 7.P/C 8.DUTY 9.CESS 4.IGST VALUE 5.RODTEP AMT 6.ROSCTL AMT
RT
0 0 4686 0
1.MAWB NO. 2.MAWB DT 3.HAWB NO. 4.HAWB DT N.O.C. 1.SNO 2.INV NO. 3. INV AMT. 4.CURRENC
DETAILS

15739734531 21793 F.INVOICE

1 EXP-21 14800 USD
4. CIN NO. 5. CIN DT. 6. CIN SITE ID SUMMARY
24PCEG11291693561100 29-NOV-24 INDEL4
PO

1.CONTAINER 2.SEAL 3.DATE 4.S No 1SR.NO 2.CHALLAN NO 3.PAYMT DT 4.AMOUNT

CHALLAN DETAILS
G. EQUIPMENT
DETAILS

EX

H
T

1.SEAL TYPE 2.NATURE OF CARGO 3.NO. OF PACKETS 4.NO. OF CONTAINERS 5.LOOSE PACKETS
I. ANNEX
DETAILS

WAREHOUSE SEALED PACKAGED 3 0 3

LE

6.MARKS & NUMBERS

1.EVENT 2.DATE 3.TIME 4.LEO NO. 6/236

J.PROCESS

5.Submission 29-NOV-24 11:17 6.LEO Date. 29-NOV-24

DETAILS

5.Assessment 8.BRC Realisation Date 31-AUG-25

7.Examination 29-NOV-24 21:40
9.LEO 29-NOV-24 22:13

10. SEZ UNIT Details

Signature Not Verified

Digitally signed by DS CENTRAL BOARD
OF INDIRECT TAXES AND CUSTOMS 08
Date: 2024.11.29 22:14:50 IST
Reason: CUSTOMS
Location: INDIA
Glossary
A: ASSESS - Assessed, EXMN - Examined, MEIS - Merchantise Export Incentive Scheme, DBK - Drawback, ROSL - Rebate of State Levies,
DEEC - Duty Exemption Entitlement Certificate, DFRC - Duty Free Replenishment Certificate,LUT - Letter of Under Taking. B: CB - Customs Broker
AD Authoized Dealer , AEO - Authorized Economic Operator, UCR - Unique Customs Reference C: DISCOU - Discount, COM - Commission,
P/C Packing Charges,D: EX. PR.- Export Promotions E: MAWB / HAWB - Master / House Airway Bill Number J:BRC- Bank Realisation Certificate

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Page 1 Of 6
 Port Code SB No SB Date
INDIAN CUSTOMS EDI SYSTEM INDEL4 6011884 29-NOV-24
CENTRAL BOARD OF INDIRECT TAXES AND CUSTOMS IEC/Br FUEPS1726J 0
DEPARTMENT OF REVENUE - MINISTRY OF FINANCE GSTIN/TYPE 07FUEPS1726J1ZB GSN
GOVERNMENT OF INDIA CB CODE AAACC6689ECH001
TYPE INV ITEM CONT
Nos 1 1 0
NEW CUSTOM HOUSE, IGI AIRPORT, NEW DELHI - 110037 PKG 3 G.WT KGS 213 * SB22291120242213

PART - II - INVOICE DETAILS

1.S.No 2.INVOICE No. & Dt. 3.P.O.No. & Dt. 4.LoC No. & Dt 5.Contract No.&Dt 6.AD code 7.INVTERM
REF
A.

1 EXP-21 28/11/2024 6360077 CF

1.EXPORTER'S NAME & ADDRESS 2.BUYER'S NAME & ADDRESS
DRx Laboratories India Inc FREEMED LDA

Y
SHOP NO - 201, PLOT NO 4, SECOND FL RUA PRINCIPAL DO PATRIOTA, LUANDA
B. TRANSACTION

LOCAL SHOPPING CENTER, ANGOLA, 06022

PARTIES

110018 CTC : FRED YARIK GREGORIO

OP
3.THIRD PARTY NAME & ADDRESS 4.BUYER AEO STATUS

1.INVOICE VALUE

TC
2.FOB VALUE 3FREIGHT 4.INSURANCE5DISCOUNT6.COMMISON 7.DEDUCT 8.P/C 9.EXCHANGE RATE
C.VAL
DTLS

14800 11211.48 300000 0 0 0 0 1 USD INR 83.6

USD USD INR
1.ItemSNo 2.HS CD 3.DESCRIPTION 4.QUANTITY 5.UQC 6.RATE 7.VALUE(F/C)
1 90275090 DIAGNOSTICS KITS/LABORATORY REAGENTS/EQU 1 NOS 14800 14800
IPMENT-MINDRAY CL900I + STANDARD ACCESSO
OR
RIES(B.NO.BK2-37001217)
XP
TE
D. ITEM DETAILS

LE

Glossary
A: Ref - Reference P.O. - Purchase Order, LoC - Letter of Credit, AD - Authorised Dealer C: VAL DTLS - Valuation Details
FOB - Freight On Board, DEDUCT - Deduction , P/C - Packing Charge D: HS CD - Harmonized System Code, UQC - Unit Quantity Code

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Page 2 Of 6
 Port Code SB No SB Date
INDIAN CUSTOMS EDI SYSTEM INDEL4 6011884 29-NOV-24
CENTRAL BOARD OF INDIRECT TAXES AND CUSTOMS IEC/Br FUEPS1726J 0
DEPARTMENT OF REVENUE - MINISTRY OF FINANCE GSTIN/TYPE 07FUEPS1726J1ZB GSN
GOVERNMENT OF INDIA CB CODE AAACC6689ECH001
TYPE INV ITEM CONT
Nos 1 1 0
NEW CUSTOM HOUSE, IGI AIRPORT, NEW DELHI - 110037 PKG 3 G.WT KGS 213 * SB22291120242213

PART - III - ITEM DETAILS

1INVSN 2ITEMSN 3.HS CD 4.DESCRIPTION 5.QUANTITY 6UQC 7.RATE 8VALUE(F/C) 9.FOB (INR) 10.PMV
1 1 90275090 DIAGNOSTICS 1 NOS 14800 14800 937280 1361008
KITS/LABORATORY
REAGENTS/EQU IPMENT-
MINDRAY CL900I + STANDARD
ACCESSO RIES(B.NO.BK2-

PY
37001217)
11.DUTYAMT 12.CESS RT 13CESAMT 14.DBKCLMD 15.IGSTSTAT 16. IGST VALUE 17. IGST AMOUNT 18SCHCOD
N LUT 00
19. SCHEME DESCRIPTION 20. SQC MSR 21. SQC UQC 22. STATE OF ORIGIN 23. DISTRICT OF ORIGIN
Free SB Involving Remittance O 1 NOS Delhi NEW DELHI

CO
24. PT Abroad 25.COMP CESS 26.END USE 27.FTA BENEFIT AVAILED 28. REWARD BENEFIT 29. THIRD PARTY ITEM
NCPTI 0 INR GNX100
RT Y No N
PO
INVOICE (1/1)

T EX
LE

GLOSSARY
FOB - Freight On Board, HS CD Harmonized System Code, UQC - Unit Quantity Code, PMV - Present Market Value, CESAM - Cess Amount
IGSTSTA - IGST Payment Status, VAL - IGST Value, PAID - IGST Amount Paid, SCHCOD - Scheme Code, SQC MSR - Standard Quantity
Measurement, comp - compensatory, PT Abroad - Preferential treatment Availed Abroad

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Page 3 Of 6
 Port Code SB No SB Date
INDIAN CUSTOMS EDI SYSTEM INDEL4 6011884 29-NOV-24
CENTRAL BOARD OF INDIRECT TAXES AND CUSTOMS IEC/Br FUEPS1726J 0
DEPARTMENT OF REVENUE - MINISTRY OF FINANCE GSTIN/TYPE 07FUEPS1726J1ZB GSN
GOVERNMENT OF INDIA CB CODE AAACC6689ECH001
TYPE INV ITEM CONT
Nos 1 1 0
NEW CUSTOM HOUSE, IGI AIRPORT, NEW DELHI - 110037 PKG 3 G.WT KGS 213 * SB22291120242213

PART - IV - EXPORT SCHEME DETAILS

A. DRAWBACK & ROSL CLAIM

1.INV SNO 2.ITEM SNO 3.DBK SNO. 4.QTY/WT 5.VALUE 6.RATE 7.DBK AMT 8.STALEV 9.CENLEV 10.ROSCTL AMT

B. AA / DFIA LICENCE DETAILS

1.INV SNO 2.ITEM SNO 3.LICENCE NO 4.DESCN OF EXPORT ITEM 5.EXP SNO 6.EXPQTY 7.UQC 8.FOB VALUE

Y
9.SION 10.DESCN OF IMPORT ITEM 11IMP SNO 12IMPQT 13.UQC 14.INDIG / IMP

OP
C. JOBBING DETAILS
1.BE NO 2.BE DATE 3.PORT CODE 4.DESCN OF IMPORTED GOODS 5.QTY IMP 6.QTY USED

D. SINGLE WINDOW DECLARATION

1.INVSN 2.ITMSN
1 1
3.INFO
CHR
TC
4.QUALIFIER
SQC
5.INFO CD 6.INFO TEXT 7.INFO MSR
1
8.UQC
NOS
1 1 DTY GCESS 0 INR
1 1 DTY RDT RODTEPY 1 NOS
1 1 ORC DOO 79
1 1 ORC EPT NCPTI
OTHER ADDITIONAL INFORMATION

1 1 ORC STO 07
OR

E. SINGLE WINDOW DECLARATION - CONSTITUENTS

1.INVSN2.ITMSNO 3.C SNO 4.NAME 5.CODE 6.PERCENTAGE 7.YIELD PCT 8.ING

F. SINGLE WINDOW DECLARATION - CONTROL

1.INVSN2.ITMSNO 3.CONTROL TYPE 4.LOCATION 5.ST DT 6.END DT 7.RES CD 8.RES TEXT
XP

G.SUPPORTING DOCUMENTS
1.INVSN2.ITMSNO 3 DOCTYPCD 4. ICEGATE ID 5. IRN 6.PARTY CD 7.ISSUE PLA 8.ISS DT 9.EXP DT
1 0 105000 CCCPL1998 2024112800125422 00 INDIA 28-NOV-24
TE

1 0 331000 CCCPL1998 2024112800125421 00 INDIA 28-NOV-24

H.INVOICE DETAILS
1.SNO 2.INVOICE NO 3.INVOICE AMOUNT 4.CURRENCY
1 EXP-21 14800 USD
I.CONTAINER DETAILS
LE

1.SNO 2.CONTAINER 3.SEAL 4.DATE

J.AR4 DETAILS
1.INVSN 2.ITMSN 3.AR4 NUMBER 4.AR4 DATE 5.COMMISSIONERATE 6.DIVISION 7.RANGE

K. THIRD PARTY DETAILS

1.INVSN 2.ITMSN 3.IEC 4. EXPORTER NAME 5. ADDRESS 6.GSTN ID AND TYPE

L. ITEM MANUFACTURER/PRODUCER/GROWER DETAILS

1.INVSN2.ITMSN 3.TYPE 4.MANUFACT CD 5.SOURCE STATE 6.TRANS CY 7.ADDRESS

M. RODTEP DETAILS
1.INVSN2.ITMSN 3. QUANTITY 4. UQC 5. NO. OF UNITS 6. VALUE
1 1 1 NOS 1 4686

Glossary
INVSN - Invoice Serial Number ITMSN - Item Serial Number A: DBK - Drawback, ROSL - Rebate of State Levies, B: DFIA - Duty Free Import
Authorization, EXP - Export , IMP - Import , UQC-Unit Quanity CodeFOB - Freight On Board D: INFO - Information CD - Code MSR - Measuremen
E: ING - Ingredient F : RES CD - Result Code, RES TXT - Result Text ST DT -Start Date G: IRN - Image Reference Number CD - Code PLA - Pla

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Page 4 Of 6
 Port Code SB No SB Date
INDIAN CUSTOMS EDI SYSTEM INDEL4 6011884 29-NOV-24
CENTRAL BOARD OF INDIRECT TAXES AND CUSTOMS IEC/Br FUEPS1726J 0
DEPARTMENT OF REVENUE - MINISTRY OF FINANCE GSTIN/TYPE 07FUEPS1726J1ZB GSN
GOVERNMENT OF INDIA CB CODE AAACC6689ECH001
TYPE INV ITEM CONT
Nos 1 1 0
NEW CUSTOM HOUSE, IGI AIRPORT, NEW DELHI - 110037 PKG 3 G.WT KGS 213 * SB22291120242213

PART - IV - EXPORT SCHEME DETAILS

N. REEXPORT DETAILS
1.INVS 2.ITMSN 3.BE SITE ID 4.BE NUMBER5.BE DATE6.BE INV SNO 7.BE ITEM S 8. BE QTY 9. BE UQC

Y
OP
TC
OTHER ADDITIONAL INFORMATION

OR
XP
TE
LE

Glossary
INVSN - Invoice Serial Number ITMSN - Item Serial Number A: DBK - Drawback, ROSL - Rebate of State Levies, B: DFIA - Duty Free Import
Authorization, EXP - Export , IMP - Import , UQC-Unit Quanity CodeFOB - Freight On Board D: INFO - Information CD - Code MSR - Measuremen
E: ING - Ingredient F : RES CD - Result Code, RES TXT - Result Text ST DT -Start Date G: IRN - Image Reference Number CD - Code PLA - Pla

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Page 5 Of 6
 Port Code SB No SB Date
INDIAN CUSTOMS EDI SYSTEM INDEL4 6011884 29-NOV-24
CENTRAL BOARD OF INDIRECT TAXES AND CUSTOMS IEC/Br FUEPS1726J 0
DEPARTMENT OF REVENUE - MINISTRY OF FINANCE GSTIN/TYPE 07FUEPS1726J1ZB GSN
GOVERNMENT OF INDIA CB CODE AAACC6689ECH001
TYPE INV ITEM CONT
Nos 1 1 0
NEW CUSTOM HOUSE, IGI AIRPORT, NEW DELHI - 110037 PKG 3 G.WT KGS 213 * SB22291120242213

PART - V - DECLARATIONS

Y
OP
TC
A. DECLARATION STATEMENT

OR
XP
TE
LE
B. AUTHORIZED
SIGNATORY

DATE AUTHORIZED SIGNATORY CHA NAME :AAACC6689ECH001

PLACE

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Page 6 Of 6