FORM GST DRC – 04

[See rule 142(2)]

Reference No:                                                                                                       Date:

To

                               GSTIN/ID

Name

                               Address

Tax Period ————-                                    F.Y. ———-

ARN –                                                  Date –

Acknowledgement of acceptance of payment made voluntarily

The payment made by you vide application referred to above is hereby acknowledged to the extent of the amount paid and for the reasons stated therein.

Signature Name Designation

Copy to –