Dutiable Commodities.
FORM 28.
Declaration to accompany Application for Drawback.
[CAP. 109
I/We, (1)
(1) Full name of person or firm entitled to
hereby declare that the goods specified in the attached Export drawback Permits(s) No.(s) ............have been actually exported, and have not been relanded, and are not intended to be relanded in any part of this Colony; and that I/we at the time of exportation was/were and still am/are entitled to drawback thereon.
Declared this
in the presence of (2)
Signature
Address
Occupation
(Signature)
.... day of
19......,
For office use only.
Drawback on the goods
specified in the above-mentioned
permit(s) assessed at the following rates:-
Total--Dollars
cents
Fee $.......
Director of Commerce and Industry.
331
and
(2) Full name of witness.
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