FORM ST-4
Form of Appeal to the Commissioner of Central Excise (Appeals)
under section 85 of the Finance Act,1994 (32 of 1994)
| 1. |
No.__________of______20___ |
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| 2. |
Name and address of the appellant |
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| 3. |
Designation and address of the officer passing the
decision or order appealed against and the date of decision or order
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| 4. |
Date of communication of the decision or order appealed
against to the appellant |
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| 5. |
Address to which notices may be sent to appellant |
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| 5A. |
(i) |
Period of dispute |
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(ii) |
Amount of service tax, if any, demanded for the period mentioned in
column (i) |
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(iii) |
Amount of refund, if any, claimed for the period mentioned in column
(i) |
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(iv) |
Amount of interest |
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(v) |
Amount of penalty |
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(vi) |
Value of the taxable service for the period mentioned in column (i) |
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| 6. |
Whether service tax or penalty or interest or all the
three have been deposited? |
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| 6A. |
Whether the appellant wishes to be heard in person? |
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| 7. |
Relief claimed in appeal |
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STATEMENT OF FACTS
Grounds of appeal
Signature of the authorised
representative, if any |
Signature of the
appellant |
Verification
I,______________________ the appellant, do hereby declare that what is stated
above is true to the best of my information and belief.
Verified today, the ____________________ day of ___________
Place:
Date :
Signature of the authorised
representative, if any |
Signature of the appellant
or his authorised representative |
Note :-
The form of appeal including the statement of facts and the grounds of appeal
shall be filed in duplicate and shall be accompanied by a copy of the decision
or order appealed against.