I__________________________________ S/O ______________________________
Managing Director/Director/Proprietor/Partner, * M/s. _________________________
___________________________ with their Regd. Office at ____________________
& Factory located at ___________________________________________________
with permanent samll/micro Enterprise Registration No.________________
Do hereby solemnly affirm and declare as under:
- The company has been a samll/micro Enterprise unit as
per the Govt. Of India definition; and has been functional
& in production at the time of GS1/UPC registration and
as on date.
- The company continue to be a samll/micro Enterprise unit;
and functional & in production as on date.
- As per books of accounts, the total investment (original
purchase value) in plant and
machinery in the Company as on _________________________________________
is Rs. ________________ (Chartered Accountant's Certificate
to this effect is attached)
Signed on this day of ________________________ dt. _____________________
Verified that the contents of the affidavit are true to the
best of my knowledge and belief.
Note:- *Strike out whichever is not applicable.
**On a stamp paper (of Rs. 5/- min) duly attested by Notary
Public (duly affixed with Notarial Stamp; and with Notary
Seal; and Notary Registration number).
TO WHOM IT MAY CONCERN
Verified from the Books of Accounts of M/s. ________________________________
with their Regd. Office at___________________________ and
Enterprise Registration No.____________________ dt._____________
that the total
Investment in plant and machinery (original purchase value)
of the company as on date________
stand as Rs.___________(Rupees______________________________).
Name & Signature of the
Chartered Accountant with stamp and
ANNEXURE-III A ( for One Time Registration Fees )
Received, with thanks a sum of Rs.* ________________________________((Rupees
________________________________only) from the Development
(MSME) towards the reimbursement of 75% of the one time registration
for allocation of GS1 Company prefix for adoption of bar-coding,
by GS1 India
(under the Ministry of Commerce).
(Stamp of the SSI unit)
Note: - The above to be submitted on Letter Head, in triplicate.
To be submitted by the Applicant on a Non-judicial
Stamp Paper of Rs. 50/-- (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 &
Notary Registration number) or First Class Magistrate.
with their Regd. Office at __________________
& Factory located at _____________
with permanent small/micro Enterprise Registration
No. _________________ dt. _______________
Do hereby solemnly affirm and declare as under:
(a) (i) That the aforesaid
Company/ Firm/ Establishment (s) have not availed reimbursement/subsidy/grant
for obtaining GS1/UPC registration under any scheme operated
by Central Government (including 0/ c DC (MSME), M/o Micro-Small
and Medium Enterprise) /State Government/Financial Institutions
(a) (ii) That the aforesaid
Company/ Firm/ Establishment (s) have claimed and received
reimbursement/subsidy/grant for obtaining GS1/UPC registration
amounting to Rs. _______________________________________ (Rupees
_________________________ From __________________________
(Name of the Central Government/State Government Department/Financial
Institutions vide draft/cheque No. _______________ Date _______________
of Name of the Bank).
(b) (i) That the aforesaid
Company/ Firm/ Establishment(s) have already applied to ____________
Name of the -Central Govt. (other than 0/o DC (MSME)/ State
Govt./ Financial institution -vide application dated ___________________
for reimbursement/subsidy/grant/incentive for obtaining GS1/UPC
(b) (ii) That the aforesaid
Company/ Firm/ Establishment (s) have not already applied
to any Central Govt./ State Govt./ Financial Institution (except
O/o DC (MSME), M/o MSME), for reimbursement/subsidy/grant
for obtaining GS1/UPC registration.
(c) That after availing reimbursement
for obtaining GS1/UPC registration from Office of DC (MSME),
Ministry of MSME, in respect of the said Company/Firm/ Establishment(s),
1 shall disclose this fact of the said Company/Firm/ Establishment(s)
at the time of claiming/reimbursement/subsidy/grant/incentive,
if any, under any other similar scheme run by Central Government/State
Government Department/ Financial Institution etc.
(d) I hereby solemnly affirm that
the information given above is correct. In case above declaration
is found wrong or incorrect or misleading, 1 do hereby bind
myself & my unit and undertake to pay to the Government on
demand the full amount received as reimbursement in respect
of above mentioned activity, within seven days of the demand
being made to me in writing.
In the presence of
(Names and Addresses of the witnesses above also to be indicated
along with signatures).
Note:- The factual status as on date under the respective
paras at (a); (b) & (c) above must be clearly indicated.
APPLICATION FORM FOR AVAILING FINANCIAL ASSISTANCE
FOR ADOPTION OF INTERNATIONAL NUMBERING STANDARDS FOR BAR
CODING AND E-COMMERCE.
- Name and address of the unit, telephone/fax No. and e-mail.
(Reg. Office & Factory Location (S)).
- Name & designation of proprietor/owner of the Small/Micro
- Details of Permanent Small/Micro Enterprise Registration
No; date of issue by Directorate of Industries/GM, DIC of
the State concerned.
(Enclose a copy of each page of permanent SSI registration
duly attested by General Manager, District Industries Centre
(DIC) or State Directorate of Industries/Director MSME-DI/Chartered
- Proof of MSME status of the unit whether Small/Micro
Enterprise as well as functional status of the unit at the
time of GS1/UPC registration and the date of application.
The following document (s) to be submitted. A certificate
(in original) from G.M., DIC/DI confirming Small/Micro Enterprise
status on date of application
An affidavit (in original) from Managing Director/Proprietor/Partner
of the SSI/Tiny unit duly sworn before a Notary Public confirming
Small/Micro Enterprise and functional status of the unit
at time of obtaining GS1/UPC registration; and as on date
(as per Annexure-I),
accompanied by Chartered Accountant Certificate of the total
investment in Plant & Machinery on the date of application
(original purchase value)
(As per Annexure -II)
- GS1/UPC registration number & date of issue by GS1 India
under Ministry of Commerce. (enclose a copy of GS1/UPC registration
certificate duly attested)
- Total Amount paid by the unit to GS1 (under Ministry
of Commerce) for allocation of unique GS1/UPC registration
number (enclose a copy of fee receipt).
- Amount claimed for reimbursement. (Pre receipted bill,
in triplicate, as per Annexure- III A).
- Details of reimbursement/grant/subsidy already received
from Central/State Government/Financial Institutions for
obtaining GS1/UPC registration Number. Furnish an undertaking/
declaration (in original) from the Managing Director/ Director/
Proprietor /Partner of the Small/Micro Enterprise units
duly Notarised. (as per the format Annexure-IV).
I declare that the particulars given in the
above statement are correct. I also undertake that any financial
assistance granted to me/my unit on the basis of this declaration
shall be liable to be refunded to the Government if at any
time any information furnished in this application is found
to be wrong or incorrect or misleading and I do hereby bind
myself and my unit to pay the Government on demand a sum equal
to the amount claimed as financial assistance in respect of
above mentioned activity, within seven days of the demand
being made to me in Writing.
Note:- The incomplete application is
liable to be rejected without any further correspondence.