Claim Form

Document Sample
Claim Form Powered By Docstoc
					                            CLAIM FORM


               National Pavilion Scheme

                                       1 April 2009

Under no circumstances should any application form and/or the claim form be altered. Amended
                 application/claim forms will not be considered for evaluation.

                         Page 1 of 6
                     Claim Form for National Pavilion Schemes

                                      Important Notice to EMIA Customers

    Customers please note that this claim form goes hand-in-hand with the National Pavilions Guidelines
    booklet. The conclusion of a successful claim is only possible if it is done with cross-reference to the
    requirements as laid out in the guidelines booklet.

                             Incomplete claims will be rejected without exception.

    This claim form must be submitted within three months after the return date from the event. Late claims will
    not be considered for payment.

    All correspondence to EMIA should be sent to one of the following addresses

                   PHYSICAL                                                          POSTAL
                   ADDRESS                                                          ADDRESS
           (Hand / Courier deliveries)                                           (Registered Mail)

                   the dti
      Export Promotion: EMIA Division
                                                                                    the dti
                Ground Floor
           Building A - Utangamiri                                      Export Promotion: EMIA Division
                                                                                Private Bag X84
     the dti Campus, 77 Meintjies Street
                 Sunnyside                                                            0001

Correspondence that has not been properly addressed to the dti can be incorrectly forwarded to other
departments. This will result in delays in the processing of your application or claim. the dti does not accept
responsibility for mail that has not been properly addressed.

An original, valid Tax Clearance Certificate is only required with the claim if not available on the Master file, not
submitted with the application and/or expired at the claim stage.

A copy of the Exporter’s Registration certificate (Customs and Excise certificate) is no longer required to be
submitted with an EMIA claim for reimbursement purposes.

The only acceptable means of payment are by cheque, bank draft, credit card or an electronic bank transfer. Bank
statements and Electronic Bank Transfers must provide the name of the beneficiary. All proof of payments except for
Bank statements drafted on the Bank's letterhead, should be stamped by the Bank.

                                                  Page 2 of 6
                                 Section A - Claim Calculation Sheet

Company trade name
(As on Tax Clearance

Name of event & country

Date of event                   From:                                      To:

Event / Claim Type                        National Pavilion                            Local Pavilion

Description of Approved expenditure item                                      Amount
                                                     Actual Expense                                 Office Use Only
as per Approval letter                                                       Approved
Economy class return air ticket
(Only for claims where the TISA Preferred                                                       R
Service Provider was utilised)

Subsistence Allowance
Number of days _________ x R 1 800

Transport cost of sailing a boat / yacht to a
foreign event

                  Total Claim                                                                   R

                                        Section B - Claim Checklist

Kindly ensure that all the required documentation is attached to the claim in the               Tick off documents
following order.                                                                                submitted to the dti

A copy of the letter of approval for the relevant trip.

Original/ certified copies of the economy class air tickets OR a copy of the “E-Ticket”
with original / certified copies of boarding passes for all the legs. Claims without
boarding passes will not be considered.
Certified copy of passport clearly showing: Personal Particulars & SA Passport control
departure & re-entry date stamps.
In the case of prior approval for the transport of boats / yachts sailed (chartered) to their
destination, the following documentation should be submitted:
Invoice from Skipper                                DA 3 - Proof vessel has left
Proof of payment                                    Certificate of fitness
F178 (Catamaran/vessel pre-sold)                    Certificate of registration
DA 550 - Bill of Entry/Exit                         Copy of customs entry into foreign port
Kindly ensure that above-mentioned documentation are either originals or
certified copies. Original or certified copies of Proof of payment for all the
relevant costs incurred during the trip
Original current/valid Tax clearance certificate (if original certificate on the
application / masterfile expired).

A fully completed credit order instruction form with a bank stamp.

A copy of a cancelled cheque or in the case of a savings account, a bank statement on
the bank's letterhead.

National Pavilion Participation Report Back

                                                Page 3 of 6
                     Section C - Declaration (To be completed by all claimants)
                                   AUTHORISED OFFICIAL OF THE ENTITY

             In my capacity as


hereby certify that the information submitted in the claim as well as the report back questionnaire is a true and
correct statement of my participation and actual expenses incurred by me/my company/organisation at the
mentioned event. I have not received any payments in this connection from any other source. I also undertake
to submit a follow-up report on the export successes achieved as a result of participation in the event, within six
months of the event. I understand that failure to submit the follow-up report could result in me/my
company/ organisation being barred from further assistance from the EMIA scheme.

I am aware that information which I have supplied will have a fundamental bearing on the adjudication of the
claim and if it, therefore, subsequently transpires that any information as per this claim is incorrect, or that
certain information was omitted, the Department of Trade and Industry (the dti) shall, without prejudice to any
other of it’s rights, be entitled to claim back any amounts already paid with interest as prescribed by the Public
Finance Management Act or to withhold the payment of any amounts due to the entity for which this claim has
been submitted.
   Signed (Authorised
   Official of Entity)
   Name in Print

                                          TO ACT AS A CONSULTANT
    The Board of Directors of

                  declare that

             Physical address

               Postal address

                    Telephone                                      Facsimile
               E-Mail address
was appointed as a consultant to act on our behalf with regard to issues pertaining our participation in the EMIA
Scheme of the Department of Trade and Industry. This appointment will remain in force until written notification
of change by the entity.
NB. This appointment does not authorise the consultant to sign any EMIA documents on behalf of the
applicant. All documents submitted to EMIA must be signed by the applicant/claimant.
   Signed (Authorised
   Official of Entity)
   Name in Print


                                                 Page 4 of 6
                              Section D - "Report-Back" Questionnaire

                             NATIONAL PAVILION PARTICIPATION
Name of participating firm

Represented by

Postal Address & Postal

Telephone                                                   Mobile Number

Fax                                                             E-mail

Exhibition Name

Size of Stand

Products Displayed

Number of South Africans on                   Number of Other Nationals
Duty                                          on Duty
                                   Comments: Suitability of this Pavilion

Type of Exhibition

Type of Visitors

Gathering of Marketing
Establishing Business
                               Comments: Your Experiences at this Pavilion

Were you satisfied with the Stand Position & Size

Were you satisfied with the Construction & Design

Were you satisfied with the Organisation

Suggestions for improvement

Services rendered by Freight Forwarding Service Provider

Services rendered by Trade Representatives

Services rendered by National Pavilion Project Team: Pretoria

Services rendered by the SA Embassy Staff

                                              Page 5 of 6
                                 Comments: Benefits of Participation
                              Country/Region Number                      Number

Geographic analysis of
enquiries received:

                                  In Host Country          In Other Countries

Names of

Other distribution channels of
Number of confirmed orders received
during the event
Number of estimate orders expected in
the next 6 months
Number of Agents /
Distributors appointed

New Technology required/ Agreement
signed/ Joint Venture Agreement?

                               General comments/ Areas of Improvement

                                           Page 6 of 6