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___
:
2.
Name and
address of the appellant
:
3.
Designation
and address of the officer passing the decision or order
appealed against and the date of decision or order
:
4.
Date of
communication of the decision or order appealed against to the
appellant
:
5.
Address to
which notices may be sent to appellant
:
5A.
(i)
Period of dispute
:
(ii)
Amount of service tax,
if any, demanded for the period mentioned in column (i)
:
(iii)
Amount of refund, if
any, claimed for the period mentioned in column (i)
:
(iv)
Amount of interest
:
(v)
Amount of penalty
:
(vi)
Value of the taxable
service for the period mentioned in column (I)
:
6.
Whether
service tax or penalty or interest or all the three have been
deposited?
:
6A.
Whether the
appellant wishes to be heard in person?
:
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.