THE KERALA VALUE ADDED TAX RULES, 2005 - Forms
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THE KERALA VALUE ADDED TAX RULES, 2005

FORM NO. 21J

DECLARATION OF A DEALER EFFECTING SALE

TO A DEALER CLAIMING REFUND

[See Rules 46(2) & 47 (1)]

Tax payers Identification No

The Assessing Authority

(with Office Address)

Central Sales Tax No.

I/we hereby certify the particulars of tax collected in relation to the sales effected to

M/s.................. (Name and address of the buyer with Traders Index Number) during the period from ..................................... to .................................. are as follows.

Particulars of Tax invoice		Name of Goods	Schedule No. & Entry No	HSN Code	Quantity	Sale Price (excluding tax) (Rs.)	Tax (Rs)	Total Sale Price (Rs)
No.	Date	Name of Goods	Schedule No. & Entry No	HSN Code	Quantity	Sale Price (excluding tax) (Rs.)	Tax (Rs)	Total Sale Price (Rs)
(1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)	(9)

Particulars of Out put tax remitted/set off/deferred(in case of remittance of tax, particulars of Cheque/Demand Draft/Chalan No. with date, Name of the Bank etc., should be furnished)

I/We declare that the particulars furnished herein are true to the best of my/our knowledge, information and belief and that no declaration has been issued earlier in respect of the above sales.

Place :

Date:

SEAL

Name, Signature & Status of the Applicant

CONFIRMATION

Certified that the invoices declared herein above have been included in the statement furnished by the dealer effecting sale for the month of .............

Place :

Date:

SEAL

Name, Designation & Signature of the Assessing Authority

Note:- The declaration shall be prepared in Triplicate. Original shall be filed with the application for refund, duplicate to the officer who confirms the declaration and Triplicate to the dealer applying for refund.