FORM - A
"(To be furnished in duplicate)*
"Statement of Form 'C' received for the quarter ending on Dt. ____/____/______
[See rule 7A of the Central Sales Tax (Orissa) Rules, 1957]
dealer
DECLARATION
I,_____________________________ (Name in Capital), submit herewith the Form 'C' in original hereby declare that the particulars furnished above are true and correct.
ACKNOWLEDGEMENT
(Received .................................... numbers of Form 'C')
* - First Copy - To be retained by the office
Second Copy - To be handed over to the dealer"