ANNEXURE 67

FORM - R
Application for refund of excise duty
[(Rule 173-S)]

To,

The Assistant Commissioner,
Central Excise,
Division ________________________
Collectorate ____________________

1. I/we claim refund of Rs. _______________________________________________________ (Rupees ___________________) on the grounds mentioned hereunder:-

(a)
(b)
(c)

2. I/ We enclosed the following documents in support of the claim.

1.
2.
3.
4.
5.

3. The amount claimed was originally paid by AR1/AR5/AR6/AR7/AR8/AR9/AR10/DD1/DD2 Treasury Challan No. ______________ dated ______________ deposited into _________ Treasury under the Head of Account III- Union Excise duties / Duty on __________________ miscellaneous receipts / by adjustmnet in account current No. _____________ dated ___________.

OR
The amount claimed was debited to account current No. ___________ on __________ against G.P. 1 No. ______________ dated ___________ vide entry at Serial No. __________________.

OR

4. The amount claimed was paid vide G. P. 1. No. ___________ dated _________ and invoice No. ______________ dated of M/s. _____________.

5. The payment of refund may please be made in my/our favour by a crossed cheque on _________ Treasury / by money order at Government cost.

6. I/we declare that no refund on this account has been claimed / received by me / us earlier.

7. I/We declare that the duty for which refund has been claimed has not been charged / realised from any other person and a copy of the price-list, relevant Gate Pass (Central Excise) like documents and invoices are enclsed.

8. I/We undertake to refund on demand being made within six months of the date of payment of any rebate erroneously paid to me/ us.

9. I/we declare that the goods received by me/us after payment of Central Excise duty for which refund has been claimed has been consumed by me/us as industrial consumer / has been sold in wholesale / retail.

Dated ___________________ Received payment Revenue Stamp (For amounts exceeding Rs. 20.00)

Signature and full address of claimant Signature of claimant

Claim of Shri/ Messrs_______________________________ has been scrutinised and found correct.
Refund of Rs. ____________________ (Rupees ________________) is sanctioned.
Certified that no refund order regarding the sum now in question has previously been passed.

Head of Account

Supdt. /A.C., of C. Ex. ___________
(SANCTIONING AUTHORITY)

Rs. _______________ credited towards consumer welfare fund established under Section 12C of the Central Excises and Salt Act, 1944.

Cheque No. ______________ dated _______________ for Rs. __________________ (Rupees ________________________) issued on ___________________ (RBI/SBI/Treasury) in settlement of this claim.

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AC of Central Excise _______________
(For use in the CA. O. s office)

Post audited certified that (i) the amount concerning which the refund is given has been credited into the Treasury (ii) order of refund has been varified with

(a) DD1/ DD2/ AR1/AR5/AR6/ AR7/AR8/AR9/AR10/T.C. No. _______________ dated ________________ Gate Pass No. _______________

OR

(b) Debit entry in account current No. __________________ dated ___________ and (ii) Refund has been noted against the original credit under my signature.