Form GST APL – 05

[See rule 110(1)]

Appeal to the Appellate Tribunal

1. GSTIN/ Temporary ID /UIN –
2. Name of the appellant –
3. Address of the appellant –
4. Order appealed against-                                     Number- Date-
5. Name and Address of the Authority passing the order appealed against –
6. Date of communication of the order appealed against –
7. Name of the representative –
8. Details of the case under dispute:
   1. Brief issue of the case under dispute
   1. Description and classification of goods/ services in dispute
   1. Period of dispute
   1. Amount under dispute:

• Market value of seized goods
• Whether the appellant wishes to be heard in person?
• Statement of facts
• Grounds of appeal
• Prayer
• Details of demand created, disputed and admitted

1. Details of payment of admitted amount and pre-deposit:

• Details of amount payable :

• Details of payment of admitted amount and pre-deposit (pre-deposit 20% of the disputed admitted tax and cess)

• Interest, penalty, late fee and any other amount payable and paid:

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.

Place: Date:

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