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Application Form Format

The document provides the format and application requirements for MSME units to claim reimbursement for expenses related to attending exhibitions under a government marketing assistance program. It includes sections for applicant details, exhibition details, category of applicant, products displayed, proof of MSME status, expenditure details with receipts, amount of reimbursement requested, declaration, certification, and pre-receipt. Applicants must fill out this format, provide supporting documents, and declare that they have not received funds from other sources for the same exhibition expenses.

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DS Systems
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103 views

Application Form Format

The document provides the format and application requirements for MSME units to claim reimbursement for expenses related to attending exhibitions under a government marketing assistance program. It includes sections for applicant details, exhibition details, category of applicant, products displayed, proof of MSME status, expenditure details with receipts, amount of reimbursement requested, declaration, certification, and pre-receipt. Applicants must fill out this format, provide supporting documents, and declare that they have not received funds from other sources for the same exhibition expenses.

Uploaded by

DS Systems
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 4

Format - 4.

0
Applicant Formats for the Activity No. – 4 & 5 for claiming reimbursement for
attending exhibition under the Marketing Assistance and Technology
Upgradation Scheme.

1. Name of the MSME unit:


2. Office address with fax no., E-mail ID and mobile no. of the owner:
3. Name and Location of Exhibition/Fair attended:
4. Category under which applied (Gen./SC/ST/Women/NER):
(Documentary evidence for the underline categories may be furnished)
5. Types of the products displayed by the unit:
6. (i) EM Number/SSI Registration/Udyog Aadhar:
(Enclosed an attested copy)
(ii) Proof of MSME status and functional status of the unit as on the date of attending the
exhibition (As per format F.4.1):
7. Details of the expenditure incurred in attending the exhibitions are as per follow:

Sr. Activity Mode of Actual Remarks


No. Journey expenditure
i Pavilion/stall/space charges upto 6.0 sq mtr.
ii To and fro actual fare by shortest distance

Total Expenditure :

All above payments should be supported by the receipts in original.

8. Kindly reimburse the amount of Rs …………(Rupees…….) towards expenditure incurred in the


participation of exhibition/fair, as per the scheme provision.
9. Pre-receipt to be furnished as per Format – 4.2.

Page 1 of 4
Declaration:

i) That the aforesaid Company/Firm/Establishment (s) have not availed reimbursement/


subsidy/ grant/ incentive for attending the exhibition/fair under any other Scheme operated by Central
Govt. (including O/o DC (MSME), M/0 MSME)/ State Govt./Financial Institution etc.

ii) I (full name)……………………..…….. S/o …………………….……Managing


Director/Director/Proprietor/Partner of M/s………….(complete address) hereby declare that the
particulars given in the application are correct. In case the statement/information furnished in the
application/documents later found wrong/incorrect/misleading, I do hereby liable to pay to the
Government on demand the full amount received by me as reimbursement in respect of above
mentioned activity, within seven days on the demand being made by the government.

Name and Signature of Managing Director/


Director/Proprietor/Partner of SSI unit (Full Name)

Page 2 of 4
Format - 4.1
CERTIFICATE

This is to certify that M/s………………………with office at…………………………& factory located


at…………………………….dated…………………..is a MSME unit as per MSME Development Act-2006
and is in production at the time of attending the exhibition, dated………… to be organized at……………...

Dated
Director of Industries/
GM (DIC)
Name & Rubber Seal
OR

AFFIDAVIT*

I ……………………………..S/o…………………. Managing Director/Director/Proprietor/Partner, *


M/s……………………… with their Regd. Office at ……………………& Factory located
at…………………………….with E.M. No……………dt………… …..do hereby solemnly affirm and declare
as under:

i. The Company/Firm/Establishment has been a MSME unit as per MSME Development Act-2006 and has
been functional & in production at the time of attending the exhibition, dated…………at…………..
ii The Company/Firm/Establishment continues to be a MSME unit; and in production as on date.

iii As per books of account, the total investment (original purchase value) in plant and machinery in the
Company/Firm/Establishment as on…………..is Rs……………………. (Chartered Accountant Certificate
dated………………. To this effect is attached).

Signed on this day of …………………..dt……………….


DEPONENT
VERIFICATION:

I do solemnly affirm that the contents of the Affidavit are true to the best of my knowledge & belief.

DEPONENT
Date:

Place:
(Note)
*On a stamp paper (of Rs.10/- min) in Delhi/ amount as applicable in the respective State duly sworn before a
Notary Public (duly affixed with Notarial Stamp; and with Notary Seal and Notary Registration number) or
First Class Magistrate.

Page 3 of 4
Format - 4.2
Name of the Industry____________________

Address:______________________________
_______________________________

Phone Number_________________________

PRE-RECEIPT (in Triplicate)

Received a sum of Rs._________ (Rupees________________). From the MSME-DI, ……………


towards the reimbursement of expenses incurred for attending the exhibition at ……………...

Rubber Stamp of the Unit


Signature of the Authorized Person (on Revenue Stamp)

Note: Please read the instructions while Preparing this Pre-Receipt.

INSTRUCTIONS

1. Please use the A-4 size paper only.


2. Please do not fill in the amount in the pre-receipt. Leave the portion blank. The office of
MSME-DI will fill it up after calculating the amount due to you.
3. Please ensure the authorized person of your unit signs at the places indicated for signatures of
the authorized person on revenue stamp.

************************

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