THE GOA VALUE ADDED TAX RULES, 2005 FORMS
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Body

FORM VAT-XVII

(See rule 32)

Memorandum of appeal to the Appellate Authority/Tribunal under section 35/36 of the Goa Value Added Tax Act, 2005. (Act 9 of 2005)

Before the Appellate Authority/Tribunal

No. ...............of ...............20.............

(To be filled in by the office of the Appellant Authority/Tribunal)

M/s.......................................... ................................................	-Appellant
Versus

The Appropriate Assessing Authority/Appellate Authority

-Respondent

1. TIN

2. Style of business

3. Status of the business (write here individual, HUF Partnership, Limited Company, Association of persons, etc as the case may be)	:
4. Location of principal place of business	:
5. Address to which notice may be sent to the appellant	:
6. Name of the Appropriate Assessing Authority /Appellate Authority passing the order	:
7. Period to which the appeal relates	:
8. Date of order	:
9. Date of service of order appealed against	:
10. Amount demanded	:

	Tax	:
	Penalty	:
	Interest	:	_________________________
	Total	:	_________________________
11. Amount paid
	Tax	:
	Penalty	:
	Interest	:	_________________________
	Total	:	_________________________
12. Amount in dispute
	Tax	:
	Penalty	:
	Interest	:	_________________________
	Total	:	_________________________
13. Relief claimed in appeal				:

14. The appellant has paid the tax assessed, interest levied and penalty imposed under the order appealed against as shown below:

	Amount paid before assessment	Paid after assessment/appeal			Balance due, if any, at the time filing of appeal Amount
	Amount paid before assessment	Amount	Treasury Receipt No.	Date	Balance due, if any, at the time filing of appeal Amount
(i) Out of admitted tax, interest & penalty
(ii) Out of disputed tax, interest & penalty

15. A Certified copy of the order appealed against is attached

16. Grounds of appeal (may be recorded in a separate sheet if the space is insufficient)

Verification

I /We .....................................the appellant (s) do hereby declare to the best of his/their knowledge and belief that the facts set out in the memorandum are true and that the amount of tax assessed or re-assessed interest and the penalty, if any, imposed or the tax penalty admitted to be due has been paid by Treasury Chalan dtd .................., copy of which is enclosed.

I/We ................................. the applicant/s above named do further declare that I/we have deposited 10% of the disputed amount of tax, interest, penalty demanded vide order under Appeal vide challan No ...................... dated ..................... a copy of which is enclosed.

Date:

Place:

Signature of appellant or person

duly authorised in writing in

his behalf by the appellant.

For use in the office of the Appellant Authority / Tribunal.

Date of receipt..............................................................................................................................................

Acknowledgment

Received from M/s .....................................................................of ....................TIN. (if any) ......................Memorandum of Appeal alongwith the enclosures mentioned therein.

Place:

Date:

Signature of receiving.

Official

(Office Seal)

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