FORM XXVI

(See sub-rule(15)of rule 41)

Application for the issue of Duplicate Refund Voucher

To,

Assistant Commissioner Commercial Tax,

Sector---------- Circle---------

I Certify that refund voucher as per particulars given below, issued to me/to my firm, has been lost:-

(a) Name and full Address of the dealer------------------------------------------------

from whose account refund was granted -------------------------------------------

(b) G.I.R. No.-------------------------------------------------------------------------------

(c) Assessment year-------------------------------------------------------------------------

(d) Registration Certificate No:

(i)Uttaranchal Value Added Tax Act-----------------------------------------

(ii)Central Sales Tax Act---------------------------------------------------------------

(e) Name and full address of the dealer / -----------------------------------------------

person whom refund was granted ----------------------------------------------------

(f) (i) Name of the person ------------------------------------------------------------------

submitting the application

(ii) Status with respect to person-------------------------------------------------------

to whom refund was granted

(g) Number and date of Refund voucher lost: No.---------------Date---------------

(h) Amount of Refund Rs.-----------(Rs-----------------------------------------------------)

(i) Refund on account of:

(i) Uttaranchal/Central

(ii) Tax/Penalty/fee/miscellaneous/interest

(2) I further certify that the aforesaid refund Voucher has been actually lost on --------and has not been encashed so far and that it will not be encashed even if traced.

(3) I also certify that in case the aforesaid refund Voucher is encashed, I and the aforesaid dealer or person to whom refund was granted, shall be jointly and severally liable to indemnify the Government on account of any loss that may be incurred by them.

DECLARATION OF THE APPLICANT

I --------------------------------------s/o Shri---------------------------------------Resident of --------------------------------------------------------------------------------------(full residential address) do hereby declare that the above information and all the statements made above are true and accurate to the best of my knowledge and belief and that nothing has been omitted. concealed or wrongly stated.