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Entry Form XI-2

FORM 21

[See rules 11(5) and 25(2)]

Refund Payment Order

 

Book No.

Voucher No.

Counterfoil order for the refund of tax/penalty under the Goa Tax on Entry) of Goods Act, 2000.

 

(1)

Refund payable to .................................................................................................................................................................................................................

(2)

Registration Certificate No. ...............................................

(3)

No. and date of order directing refund .......................................................................................

(4)

Year of assessment to which refund relates .............................

(5)

Amount of refund .........................................................

 

You are also informed that failure to comply with the terms of this notice is an offence punishable under Rule 41.

 

 

Place:

 

Date :

 

 

Designation

Signature Asst./Entry Tax Officer

Signature of the receipient of

Refund Payment order

 

Date of encashment of the Refund payment order .....................

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