Designation and address of the officer passing the order appealed against –
Date of communication of the order appealed against –
Name of the authorized representative –
Details of the case under dispute –
Brief issue of the case under dispute –
Description and classification of goods/ services in dispute-
Period of dispute-(iv)Amount under dispute:
Description
Central tax
State/ UT tax
Integrated tax
Cess
a) Tax/ Cess
b) Interest
c) Penalty
d) Fees
e) Other charges
(v) Market value of seized goods
Whether the appellant wishes to be heard in person – Yes / No
Statement of facts:-
Grounds of appeal:-
Prayer:-
Amount of demand created, admitted and disputed
Particulars of demand/
Particulars
Central tax
State/ UT tax
Integrated tax
Cess
Total amount
refund
Amount of demand created (A)
a) Tax/ Cess
< total >
< total >
b) Interest
< total >
c) Penalty
< total >
d) Fees
< total >
e) Other charges
< total >
Amount of demand admitted
a) Tax/ Cess
< total >
< total >
b) Interest
< total >
c) Penalty
< total >
d) Fees
< total >
(B)
e) Other charges
< total >
Amount of demand disputed (C)
a) Tax/ Cess
< total >
< total >
b) Interest
< total >
c) Penalty
< total >
d) Fees
< total >
e) Other charges
< total >
Details of payment of admitted amount and pre-deposit:-
Details of payment required
Particulars
Centra l tax
State/ UT tax
Integr ated tax
Cess
Total amount
a) Admitted amount
Tax/ Cess
< total >
< total >
Interest
< total >
Penalty
< total >
Fees
< total >
Other charges
< total >
b) Pre-deposit (10% of disputed tax)
Tax/ Cess
< total >
Details of payment of admitted amount and pre-deposit (pre-deposit 10% of the disputed tax and cess)
Sr. No.
Description
Tax payable
Paid through Cash/ Credit Ledger
Debit entry no.
Amount of tax paid
Central tax
State/UT tax
Integrated tax
CESS
1
2
3
4
5
6
7
8
9
1.
Integrated tax
Cash Ledger
Credit Ledger
2.
Central tax
Cash Ledger
Credit Ledger
3.
State/UT tax
Cash Ledger
Credit Ledger
4.
CESS
Cash Ledger
Credit Ledger
Interest, penalty, late fee and any other amount payable and paid
Sr. No.
Description
Amount payable
Debit entry no.
Amount paid
Integrated tax
Central tax
State/UT tax
CESS
Integrated tax
Central tax
State/UT tax
CESS
1
2
3
4
5
6
7
8
9
10
11
1.
Interest
2.
Penalty
3.
Late fee
4.
Others (specify)
Whether appeal is being filed after the prescribed period – Yes / No
If ‘Yes’ in item 17 –
Period of delay –
Reasons for delay –
Verification
I, < >, hereby solemnly affirm and declare that the information given hereinabove is true and correct to the best of my knowledge and belief and nothing has been concealed therefrom.
