Service Tax Refund Form R

Originally posted by :Dilip Darji
"	ANNEXURE-67 FORM - R Application for refund of excise duty [(Rule 173-S)] To The [Assistant Commissioner], Central Excise, Division ________ Collectorate ___________ 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 into ______ 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. 1. No. ________ dated ______ vide entry at Serial No. __________. OR 4. The amount claimed was paid vide [G.P. 1.] 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 price-list, relevant Gate Pass (Central Excise) like documents and invoices are enclosed. 8. I/We undertake to refund on demand being made within six months 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. 20.00]) 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 _____________ (RBI/SBI/Treasury) in settlement of this claim. ________________________________________________________________________________________________________________________ AC of Central Excise_______________ (For use in the CA.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 ___________ Gate Pass No. _______________. OR (b) Debit entry in account current No. ____________ dated ____________ and (ii) Refund has been noted against the original credit under my signature. * * * * * * _______	"