FORM XII

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. ................. furnished to me by Shri/Messrs .................... a registered dealer having Tax Payers' Identification No. ............. in the State of ............................................................. is lost/destroyed/stolen from my custody.

And I, the aforesaid Shri ........................................ do hereby undertake to hold harmlees 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 assings and each one of the other persons having any share, title or interest in the aforesaid 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

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Manager

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Principal Officer