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 | : |
STATEMENT OF FACTS
Grounds of appeal
Signature of the authorized
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 _________20__
Place:
Date :
Signature of the authorized
representative, if any | Signature of the appellant
or his authorized 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.