{5} {6}
Image Government of the People's Republic of Bangladesh
National Board of Revenue
Input-Output Co efficient Declaration Mushak - 4.3
(See Rule 21)
1. Name of the organization : {0}
2. Address : {1}
3. Bin : {2}
4. Date of Submission : {3}
5. Date of first delivery of the product / service as per coefficient declaration : {4}
SL No HS Code of the product / Service Name and description of the supplyable product / service (with brand name in applicable cases) Unit of Supply Details of quantity and purchase price of all materials/raw materials and packing materials used in the supply of a single product/service (including percentage of material-based wastage) (Details of Value addition) Remarks
Description Quantity with wastage Purchase price Amount of waste Rate of percentage Particulars of Value addition Value
1 2 3 4 5 6 7 8 9 10 11 12
Name of the person in charge of the organization :
Designation :
Signature :
Special Notes - Seal :
1. The input production coefficient declaration must be submitted to the online VAT computer system or to the office of the concerned departmental officer within 15 days of the first supply of any product or service.
2. If the price of goods changes by more than 7.5% of the price of inputs/raw materials, a new declaration must be submitted.
3. A copy of the bill of entry or Mushak 6.3 must be attached as supporting document for the purchase of goods.