The Orissa Value Added Tax Rules, 2005 FORMS
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FORM VAT- 402 A Omitted w.e.f. 01-07-2017

DECLARATION

[See rule 81 (2)]

01. Name and address of the casual dealer or person to whom issued.

02. Name and address of the consignor of goods:

3. TIN of the Consignor	4 CST No. of the Consignor
5 Place of Dispatch of Goods	6 State of Dispatch of Goods

7. Actual/ Expected Date of despatch of goods

8. If the consignor is despatching or transporting the goods:-
in pursuance of a sale for delivery to the buyer	after purchasing the goods	Any other reason (please specify)

9. Name and address of the consignee of the goods. (if different from whom this form is issued to):

10. TIN of the Consignee

11 CST No. of the Consignee

12. Details of Commodities.

Sl	Commodity Code	Invoice		Quantity	Value (In Rupees)
Sl	Commodity Code	No.	Date	Quantity	Value (In Rupees)

13. Railway receipt / Air consignment note / Bill of lading /any other Transport document number. & Date:

14. Name of entry/exit check gate:

15. Vehicle Regd. No.:

VERIFICATION

16.

I______________________________________ of (address) __________________________________ _____________________________ the consignor /consignee of the goods covered in this declaration do hereby solemnly affirm that the particulars furnished above are true and correct to the best of my knowledge and belief.

I do hereby agree to pay the taxes and other dues, if applicable under relevant Act(s) I Rule(s), on the goods covered in this declaration, at the entry / exit border Check Gate / RR Unit etc. of Commercial Taxes, Odisha.

Date _____/_____/ ______

Signature of the Consignee / Consignor to whom this declaration form is issued