FORM GST APL – 03
[See rule 109(1)]
Application to the Appellate Authority under sub-section (2) of Section 107
- Name and designation of the appellant
Name-
Designation-
Jurisdiction-
State/Center-
Name of the State - GSTIN/ Temporary ID /UIN
- Order no. Date-
- Designation and address of the officer passing the order appealed against
- Date of communication of the order appealed against
- Details of the case under dispute-
(i) Brief issue of the case under dispute-
(ii) Description and classification of goods/ services in dispute-
(iii) Period of dispute-
(iv) Amount under dispute-
Description | Central tax | State/ UT tax | Integrated tax | Cess |
---|---|---|---|---|
a) Tax/ Cess | ||||
b) Interest | ||||
c) Penalty | ||||
d) Fees | ||||
e) Other charges |
7. Statement of facts-
8. Grounds of appeal-
9. Prayer-
10. Amount of demand in dispute, if any –
Particulars of demand/refund, if
any |
Particulars |
Central tax |
State/ UT tax |
Integrated tax |
Cess |
Total amount |
||
Amount of demand created, if any
(A) |
a) Tax/ Cess |
<total> |
<total> |
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b) Interest |
< total> |
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c) Penalty |
< total> |
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d) Fees |
< total> |
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e) Other Charges |
< total> |
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Amount under dispute (B) |
a) Tax/ Cess |
< total> |
< total> |
|||||
b) Interest |
< total> |
|||||||
c) Penalty |
< total> |
|||||||
d) Fees |
< total> |
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e) Other Charges |
< total> |
Place:
Date:
Signature
Name of the Applicant Officer:
Designation:
Jurisdiction: