Form A-IX Application for Provisional Refund under section 69 of the Bihar Value Added Tax Act, 2005 [See rule 44(1)] Office of the .................................................................................. of Commercial Taxes ...................................................................................Circle To, The ........................................................................... .................................................................................................................... Circle. I ................................................................................................... (full name), son of ...................................................................................................... (full name) hereby apply for provisional refund of tax in excess of my liability paid by me. The particulars are detailed below - 1. Name and Style of Business ........................................................................................................................................................................................ ........................................................................................................................................................................................ 2. Taxpayer Identification No. ........................................................................................................................................................................................ 3. Period to which the refund relates ....................................................................................................................................................................... 4. Details of payment made: Cheque/DD Number Challan Number Date Amount 1. ................................................................. .................................................... .................................................... .................................................... 2. ................................................................. .................................................... .................................................... .................................................... 5. Amount of Refund Claimed ........................................................................................................................................................................................ 6. Manner of Refund Preferred: Payment Order Refund by Adjustment 7. If refund by adjustment is preferred, mention the period against which adjustment is being claimed .......................................................................................................................... 8. Nature of security to be submitted against the amount of provisional refund .......................................................................................................................... 9. Grounds of Refund ..................................................................................................................................................................................................................... ............................................................................................................................................................................................................................................................................................ DECLARATION I, ..........................................................................................., the petitioner do hereby declare that what is stated herein true to best of my knowledge and belief and that no application for refund of the above amount has been made by me or on my behalf this date. I undertake to deposit the provisional amount received by me as and when required and it is also hereby agreed that in the event of failure of the above bounden to deposit the amount provisionally received, the authorities are to cash the security deposited by me. Place ................................................... Signature ................................................................................ Date ................................................... Status/Designation ................................................................................
