Tax Remission Form

Annexure I

(See Rule 28(2-A)(e))

Please fill in Capital letters where applicable and sign the declaration.

Date --/--/20--

Period From --/--/20-- To --/--/20--

Annexure I

TAX REMISSION CLAIM FORM

1. Name & Address of the Industrial Unit ..................................................

2. Tax Payer Identification Number (TIN) ..................................................

3. Circle & Division in which registered ..................................................

4. Date of filing the quarterly return ..................................................

5. Tax period to which tax remission claim pertains ..................................................

6. Quantum of taxable sales for the tax period ..................................................

7. Total amount of price adjustment for the tax period made in selling price ..................................................

8. Total amount of tax collected for the tax period ..................................................

9. Amount of tax remission claimed ..................................................

10. Whether declaration for as per Annexure II enclosed ..................................................