The designation and address of the authority
passing the order appealed against.
2.
The number and the date of the order
appealed against.`
3.
Date of communication of a copy of the order
appealed against.
4.
State / Union territory and the
Commissionerate in which the order / decision of assessment /
penalty / interest was made.
5.
Designation and address of the adjudicating
authority in cases where the order appealed against is an
order of the Commissioner (Appeals)
6.
Address to which the notices may be sent to
the appellant.
7.
Address to which the notices may be sent to
the respondent.
8.
Whether the decision or order appealed
against involved any question having a relation to the value
of the taxable service for purposes of assessment; if not ,
difference in tax or tax involved, or amount of interest or
penalty involved, as the case may be.
8A.
(i)
Period of dispute
(ii)
Amount of tax if any, demanded for the period mentioned
in item (i)
(iii)
Amount of refund, if any, claimed for the period
mentioned in item (i)
(iv)
Amount of interest involved.
(v)
Amount of penalty imposed.
9.
Whether tax or penalty / interest is
deposited; if not, whether any application for dispensing with
such deposit has been made ( a copy of the challan under which
the deposit is made shall be furnished).
9A.
Whether the appellant wishes to be heard in
person.
10.
Reliefs claimed in
appeal.
STATEMENT OF
FACTS Grounds of appeal
(i)
(ii)
(iii)
(iv)
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 :-
(1)The appeal including
the statement of facts and the grounds of appeal shall be filed in
quadruplicate and shall be accompanied by an equal number of copies
of the order appealed against (one of which at least shall be a
certified copy).
(2) The form of appeal
shall be in English (or Hindi) and should set forth, concisely and
under distinct heads, the grounds of appeal without any argument or
narrative and such grounds be numbered consecutively.
(3) The fee of Rs. 200
required to be paid under the provisions of the Act shall be paid
through a crossed bank draft in favour of the Assistant Registrar of
the Bench of the Tribunal on a branch of any nationalized bank
located at the place where the Bench is situated and demand draft
shall be attached to the form of appeal.