FORM 23 [See rule (14)] Application for permission to pay finally assessed tax under the Goa Tax on Entry of Goods Act, 2000, in installments. To, ............ ............ ............ I, ........... son of ......... being an assess ...... under the Goa Tax on Entry of Goods Act, 2000 hereby apply for permission of pay in installment the finally assessed tax due from me as per the following details:- (1) Name and address of the applicant (2) Registration No. (if any) (3) Sum of payment of finally assessed tax for which instalments are sought (4) If the sum in column 3 are payable under an order of assessment, the date of service of Notice in Form -10 (5) The period within which permission to pay the sum in column 3 is sought (6) Reasons for the applicant's inability to pay the tax/other amount due within the due date (7) Any other relevant information which the applicant may desire to furnish. DECLARATION (a) I hereby declare that to the best of my knowledge and belief the information contained in the above application is true and correct. (b) I hereby declare that no application for instalment has been made to any other authority in regard to the sum mentioned in column 3. (c) I hereby declare that no sums other than those mentioned in column 3 are due from me on the date of making this application. (d) I hereby undertake to pay interest at the rate of 18 per cent per annum along with each instalment on the sums remaining unpaid from time to time. (e) I hereby undertake to furnish necessary security to the satisfaction of the concerned assessing authority for the recovery of the sums in relation to which the grant of instalments is applied for. Signature of the Assessee, Name and address Place: of the person signing with status Date : and relationship to the Assessee (whether Proprietor, Manager, Director, Partner, etc.)
