THE KERALA VALUE ADDED TAX RULES, 2005

FORM NO. 21 D

APPLICATION FOR REIMBURSEMENT

OF TAX ILLEGALLY COLLECTED

(See Rule 56)

To

The Registering Authority

(with Office Address)

I/We................. & address)claim reimbursement of Rs............... Rupees....................................... (in words) being the amount collected from me by M/s............................. (Name & address) TIN / PIN ................., in contravention of subsection (2)/(3)/(4) of section 30 of the Kerala Value Added Tax VAT Act, 2003 and whose place of business is situated in your jurisdiction. The details of the amount so collected are as follows:

CERTIFICATE

I/We ...................... (Name & address of the selling dealer) having place of business at ................ holders of TIN / PIN .............. do hereby certify that I/We have collected an amount of Rs ............ ............ (In words) from Sri/M/s........................ (Name & address of the buyer) in contravention of section 30 of the Kerala Value Added Tax VAT Act, 2003. The details of such collection given in the above application of the said Sri/M/s ............ ........... are correct to the best of my knowledge and belief. The collected amount of Rs. .......... has been deposited in Government Treasury/Designated Bank under Chalan No.............. dated .............. or included in that chalan or chalans, receipted copies of which have been duly filed in your office/ remitted by cheque/demand draft No............ dated............ drawn on .................. (Name and address of Bank) or fully/ partially set-off against input tax or deferred.