FORM XI

Bond of Indemnity

[See Rule 6(d)]

I, Shri ...................................................., son of Shri .................................................................. residing at .................................. P.S. ............................................. P.O. ..................................... District ........................ Proprietor/Partner/Manager/Principal Officer of the business known as ............................. at .......................................... and possessing a certificate of registration bearing Tax Payers' Identification No. ........................................ in the State of Orissa issued under the Central Sales Tax Act, 1956, do hereby declare that the declaration form bearing serial No. ..................................... issued to me by the Sales Tax Officer .................................... Circle/Assistant Commissioner of Sales Tax........ Range, on ....................................... is lost/destroyed/ stolen* (1) from my custody before being filled in or signed by me, (2) from my custody after being filled in and signed by me but before despatch to the selling dealer, namely ....................................................... (3) in transit after being duly filled in and signed by me and despatched to the selling dealer, namely .....................

And I, the aforesaid Shri ................................ do hereby undertake to hold harmless and to indemnify the Government against any loss arising out of the aforesaid loss of declaration for me.

And I bind myself, my heirs, executors, administrators and assigns and each one of the other persons having any share, title or interst in the aforsaid business and his heirs, executors, administrators and assigns jointly and severally for holding harmless and indemnifying the Government for any such loss as aforesaid.

Proprietor

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Partner/Manager/Pricipal Officer

*Strike out whichever is not necessary.