Form 4Va – Fill Out and Use This PDF

2.

Period of assessment

From _ _/_ _/_ _ _ _

To _ _/_ _/_____

3.

The appeal/application is made against order

passed under section(s)

4.

Date of order against which the appeal/application

is made

5.

Name of the officer who passed the order

6.Designation of the officer who passed the order

7.Date of receipt of the relevant notice of demand, if

any

8.

Date of receipt of order against which the petition

/application is made

9.Appeal Case Number, if any (only for revision

after appeal or for review )

K.

Particulars of *provisional assessment or any other assessment relevant for *memorandum of appeal

/application for revision /application for

review under the C.S.T. Act, 1956:---

Sl.No.

Particulars

Amount as per order/demand

Admitted

notice(Rs.)

Amount (Rs.)

Turnover

Tax,interest,

Turnover

Tax,

etc.

interest,

etc.

I

Turnover of export sales under

section 5(1)

II

Turnover of sales in course of

import under section 5(2)

III

Turnover of sales in course

of

export under section 5(3)

IV

Stock transfer outside West Bengal

exempt under section 6A

Sl.No.

Particulars

Amount as per order/demand

Admitted

notice (Rs.)

Amount (Rs.)

Turnover

Tax,interest,

Turnover

Tax,

etc.

interest,

etc.

V

Turnover of inter-state sales from

West Bengal under section 3

VI

Turnover of subsequent inter-state

sales exempt under section6(2)

VII

Turnover of inter-state sales

exempt under section 8(5)

VIII

Turnover of inter-state sales

exempt under section 8(6)

IX

Turnover of taxable

inter-state

sales and tax payable thereon

Amount of ITC/ITR

adjusted

X

under rule 8D of CST (WB) Rules,

1958

XI

Net Tax Payable under the CST

Act, 1956

XII

Deferment of tax under rule8A of

the CST(WB) Rules, 1958

XIII

Penalty imposed for late

submission of return

XIV

Late fee payable for late

submission of return

XV

(a)Interest payable for the period for

late payment of admitted taxes

(b) Interest payable for the period for

other reasons

XVI

Total amount of tax, interest, penalty

and late fee paid before assessment

XVII

Any other item not specified above

(specify)

(Amount in Rs.)

Sl.No.

Particulars

Turnover

Tax/tax credit/

/interest/latefee/penalty in

dispute

I

Turnover of taxable inter-state sales and

tax

payable thereon

II

Amount of ITC/ITR adjusted under rule 8D of CST(WB) Rules,1958

III

Net tax payable under the C.S.T. Act, 1956

IV

Interest

payable under the C.S.T. Act, 1956

V

Late fee

payable under the C.S.T. Act, 1956

VI

Penalty for late submission of return under the C.S.T. Act ,1956

VII

Total amount of tax, interest, penalty and late fee in dispute

VIII

Any other item not specified above ( specify)

Particulars

Amount of

Admitted

Disputed

demand as per

amount (Rs.)

amount (Rs.)

order/notice (Rs.)

(a) Order imposing penalty under the C.S.T. Act,

1956, read with section.....................[specify if

applicable] of the *WBVAT Act, 2003/ WBST

Act,1994 :

(b) Order for demand of security /additional

security under the C.S.T. Act, 1956 read with

section………. [ specify if applicable] of the

*WBVAT Act, 2003/WBST Act, 1994 :

(c) Amount of demand by order under

section.............. of the C.S.T. Act, 1956 read with

section .............. [specify if applicable] of the

*WBVAT Act, 2003/ WBST Act, 1994:

(d) Any other order under section ………….of the

State the nature of

order [e.g. amendment of RC;

C.S.T.Act, 1956:

forfeiture or refund of security etc.]

(A) Before order

(B) After order referred to in *serial 10/ serial 11 above is passed

referred to in

serial 10 /

[if payment of one type is by more than one challan, mention the total amount

serial 11 above is passed

and attach separate sheet]

Particulars

Amount(Rs.)

Particulars

Amount(Rs.)

Date

Name of

Branch

Challan

Bank

No.

Tax

Tax

Interest

Interest

Penalty

Penalty

Late fee

Late fee

Security

Security