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FORM VAT- XVII

(See rule 32)

Memorandum of appeal to the Appellate Authority/Tribunal under section 35/36 of the Goa Value Added Tax Act, 2005

(Act 9 of 2005)

Before the Appellate Authority/Tribunal

No..........of .....20....

(To be filled in by the office of the Appellant Authority/Tribunal)
M/s.......................

............................
- Appellant
Versus
The Appropriate Assessing Authority/Appellate Authority - Respondent
(1) TIN
           
:
(2) Style of business:
(3) Status of the business (write here individual, HUF
Partnership, Limited Company, Association of
persons, etc as the case may be)
:
(4) Location of principal place of business:
(5) Address to which notice may be sent to the appellant:
(6) Name of the Appropriate Assessing Authority/Appellate Authority passing the order:
(7) Period to which the appeal relates:
(8) Date of order:
(9) Date of service of order appealed against:
(10) Amount demanded:
 Tax :

Penalty:

Interest:__________

Total:____________
(11) Amount paid
 Tax :

Penalty:

Interest:__________

Total:____________
(12) Amount in dispute
 Tax:

Penalty:

Interest:__________

Total:____________
(13) Relief claimed in appeal
(14) The appellant has paid the tax assessed, interest levied and penalty imposed under the order appealed against as shown below :
 Amount paid before assessmentPaid after assessment/appealBalance due, if any,at the time of filingof appealAmount
AmountTreasury Receipt No.Date 
(i) Out of admitted tax, interest & penalty     
(ii) Out of disputed tax,interest & penalty     

(15) A Certified copy of the order appealed against is attached

(16) Grounds of appeal (may be recorded in a separate sheet if the space is insufficient

Verification

I/ We ..........the appellant (s) do hereby declare to the best of his/their knowledge and belief that the facts set out in the memorandum are true and that the amount of tax assessed or re-assessed interest and the penalty, if any, imposed or the tax and penalty admitted to be due has been paid by Treasury Chalan dtd........,copy of which is enclosed.


Date:

Place:




Signature of appellant or person
duly authorised in writing in
his behalf by the appellant.
For use in the office of the Appellant Authority/Tribunal.




Date of receipt..................

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

Acknowledgment


Received from M/s ............................of ............TIN. (if any)................. Memorandum of Appeal alongwith the enclosures mentioned therein.
Place:


Date:


Signature of receiving Official

(Office Seal)




.....................................................................................................................
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Commissioner of Commercial Taxes, Vikrikar Bhavan, MG Road, Panjim, Goa, India. Ph.:0832-2229225
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