THE GOA VALUE ADDED TAX RULES, 2005 FORMS
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FORM VAT - XVII A

(See rule 38A)

Memorandum of Review under section 39A of the Goa Value Added Tax Act, 2005

(Goa Act 9 of 2005)

Before the ..............................(Name of Authority)

No ................ of ....20....

(To be filled in by the office of the Reviewing Authority)

M/s ........................................................................................... — Applicant

..................................................................................................

Versus

The Appropriate Assessing Authority .. — Respondent

(1)	TIN	\|
(2)	Style of business	:
(3)	Status of the business (write here individual, HUF Partnership, Limited Company, Association of persons, etc. as the case may be)	:
(4)	Location of principal place of business	:
(5)	Address to which notice may be sent to the Applicant :
(6)	Name of the Appropriate Assessing Authority passing the order	:
(7)	Period to which the Review relates	:
(8)	Date of order against which Review is filed	:
(9)	Date of service of order to be Reviewed	:
(10)	Amount demanded
	Tax	:
	Penalty	:
	Interest	: ..........................
	Total	: ..........................
(11)	Amount paid
	Tax	:
	Penalty	:
	Interest	: ..........................
	Total	: ..........................
(12)	Amount in dispute
	Tax	:
	Penalty	:
	Interest	: ..........................
	Total	: ..........................
(13)	Relief claimed in Review	:
(14)	The Applicant has paid the tax assessed, interest levied and penalty imposed under the order to be reviewed as shown below:

	Paid after assessment			Date	Balance due, if any at the time of filing of Review Application
	Amount paid before assessment	Amount	Treasury Receipt No.	Date
(i) Out of admitted tax, interest & penalty
(ii) Out of disputed tax, interest & penalty

(15) A Certified copy of the order to be reviewed is attached

(16) Grounds of review (may be recorded in a separate sheet if the space is insufficient)

Verification

I/We ................... the applicant (s) do hereby declare to the best of his/their knowledge and belief that the facts set out in the memorandum are true and that whole of the amount of tax assessed or re-assessed, interest and the penalty, if any, imposed or the tax and penalty admitted to be due has been paid by Treasury Challan dated ................., copy of which is enclosed.

I/We ........................ the Applicant (s) above named do further declare that I/we have deposited 10% of the disputed amount of tax, interest, penalty demanded vide order under review vide challan No .......................dated .................., a copy of which is enclosed.

Date:	Signature of Applicant or person duly authorised in writing in his behalf by the Applicant.
Place:

For use in the office of the Reviewing Authority.

Date of receipt of Memorandum of Review ...........................................

Acknowledgment

Received from M/s .................................. Of ................................TIN (if any) ....................... Memorandum of Review alongwith the enclosures mentioned therein.

Date:	Signature of receiving Official
Place:	Signature of receiving Official
(Office Seal)