THE ASSAM VALUE ADDED TAX RULES, 2005

FORM 37-A

[Sec Rule 29A]

APPLICATION FOR REFUND

01-Name and address of the person claiming refund

02 Name of the Organization

03 Date(s) of purchases(s) for which refund is claimed

04-Amount already paid along with retail invoice no. and date of payment; and

05-The amount of refund claimed and grounds thereof.

VERIFICATION

I ........................................... (Proprietor/director/secretary or other authorised person) hereby declare that the particulars given herein are correct and hereby apply for refund under the Assam Value added Tax Act, 2003.

Signature of Taxpayer or authorised officer