Word Form R – Fill Out and Use This PDF

FORM R

Application for refund of excise duty (Service

tax)

(Rule 173S)

TO

The Assistant Commissioner,

Central Excise,

Division …………………..

Commissionerate

1.I/We, claim refund of Rs ……………. (Rupees………………………..) on the grounds mentioned hereunder: -

(a)

(b)

(c)

2.I/We enclose the following documents in support of the claim 1.

2.

3.

4.

5.

3.The amount claimed was originally paid by AR1/AR5/AR6/AR7/ AR8/AR9/AR10/DD1/DD2 Treasury Challan No . ..............................

dated ………….. deposited in to ……………. Treasury under the Head of Account III-Union Excise duties/Duty on

.................................	miscellaneous receipts/by adjustment in
account current No .	............... dated ………………
	OR

The amount claimed was debited to account current No……………

on ……………… against G.P.I. No …………….. dated ……………

vide entry at Serial No ………….

OR

4.The amount claimed was paid vide G.P.I. No ……………. dated

…………….. and invoice No………….. dated …………… of M/s

…………….

5.The payment of refund may please be made in my/our favour by a

crossed cheque on ……………….. Treasury/by money order at

Government cost.

6.I/We declare that no refund on this account has been claimed/received by me/ us earlier.

7.I/We declare that the duty for which refund has been claimed has not been charged/ realised from any other person and a copy of the pricelist, relevant Gate Pass (Central Excise) like documents and invoices are enclosed.

8.I/We undertake to refund on demand being made within six months

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of the date of payment of any rebate erroneously paid to me/us.

9.I/We declare that the goods received by me/us after payment of Central Excise duty for which refund has been claimed has been consumed by me/us as industrial consumer/has been sold in wholesale/ retail.

Dated ....................

Signature and full address of claimant

Received payment

Revenue Stamp (For amounts exceeding Rs. 500.00)

Signature of claimant

Claim of Shri/Messrs …………….. has been scrutinised and found correct.

Refund of Rs………………. (Rupees …………… ) is sanctioned.

Certified that no refund order regarding the sum now in question has previously been passed.

Head of Account

Supdt./A.C. of C.Ex………………

(SANCTIONING

AUTHORITY)

Rs…………….. credited towards consumer welfare fund established under

section 12C of the Central Excises and Salt Act, 1944

Cheque No…………. dated …………..for Rs. …………….. (Rupees

………………..) issued on ................... in (RBI/SBI/ Treasury settlement of

this claim.

A.

C

.

of

C e nt ra l

E x ci s e

...

...

...

..

(F or use of the

RUSHABH INFOSOFT LTD.

C.A.O's

office)

Post-audited certified that (i) the amount concerning which the refund is given has been credited into the Treasury, (ii) order of refund has been verified with

(a)DD1/DD2/AR1/AR5/AR6/AR7/AR8/AR9/AR10/T.C. No……………….dated ………….. Invoice No……..

OR

(b)Debit entry in account No…………….., dated ……………and (ii) Refund has been noted against the original credit under my signature

……………………………….

CAO

RUSHABH INFOSOFT LTD.