The Orissa Entry Tax - Forms
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FORM 34

[See sub-rule (1) of rule 23 A]

FORM OF MEMORANDUM OF APPEAL TO THE TRIBUNAL

01.

Office address :

.................................................................

Date

Month

Year

02.

TIN/SRIN/Identification No.

03.

Appellant(s)

(Name and full address)

Versus

Respondent(s)

(Full address)

04.	Circle/Range/LTU in which assessment was made
05.	Tax period(s) for which assessment was made
06.	Designation of the assessing authority passing the order of assessment/the order of penalty, now appealed against and the date of his order
07.	Designation of the appellate authority passing the order in appeal under Section 16 of the Act and the date of his order
08.	Date of receipt of the appellate order under Section 16 of the Act by the appellant(s)
09.	Full address to which notices may be sent to the appellant(s)
10.	(i) Turnover of purchases of scheduled goods on which Entry Tax is leviable.
	(ii) Turnover of sale of scheduled goods on which Entry Tax is leviable.

As determined by STO/ACST

As determined by ACST/Addl. CST

As claimed by the appellant

(i) Gross turnover

(ii) Taxable turnover

(iii) Tax

(iv) Interest

(v) Penalty

11.	Assessment of tax/penalty/interest in dispute and fee paid thereon
12.	GROUNDS OF APPEAL

13.

VERIFICATION

I______________________son of _____________________________ (status)_____________________________ of the business known as M/s._____________________ at (address)_____________________, the appellant(s), do hereby declare that what is stated in the memorandum is true to the best of my knowledge and belief.

Place__________________
	Signature of the appellant
Date_________________

VERIFICATION

I_____________________(designation) ________________________ on behalf of the State Government do hereby declare that what is stated in this memorandum is true to the best of my knowledge and belief based on official records.

Place__________________	Signature

Date__________________	Designation