THE ASSAM VALUE ADDED TAX RULES, 2005

FORM-42

[See Rule 30(1)(a)]

APPLICATION FOR REFUND

To,

The Prescribed Authority,

Unit_____________.

Sir,

I hereby apply for release/refund of security furnished by me, the particulars are given below:-

(a) Name and address of the person claiming refund

(b) Name and style of business together with number of the certificate of registration, if any.

(c) Tax period for which refund is claimed

(d) Nature of the amount claimed as refund - ; (please specify if Tax/Penalty/Interest/Others)

(e) Amount already paid together with Challan Number and date of payment

(f) The amount of refund claimed and grounds thereof.

VERIFICATION

I hereby solemnly declare that the above statements are true to the best of my knowledge and belief.