FORM ENT XIII (See rule 21) MEMORANDUM OF APPEAL TO THE APPELLATE AUTHORITY /TRIBUNAL UNDER SECTION 6D(1)/6D(3) OF THE GOA ENTERTAINMENT TAX ACT 1964 BEFORE THE APPELLATE AUTORITY/TRIBUNAL No........of 200. M/S Appellant ........... ........... ............. Name of Assessing Authority/ Appellate Authority which has passed the order under appeal/review Date of Order Period to which appeal pertains Date of Service of order Demand created in disputed order (Rs.) Demand created in disputed order (Rs.) Demand admitted (Rs.) Balance Demand (Rs.) Admitted Tax /Fees Payment Proof (Challan no.and date) Tax Penalty Interest Total Grounds of Appeal: (Signature of Appellant/Representative) RC No. of the Dealer Status: List of annexures: VERIFICATION I/We................do hereby declare that the facts set out in the memorandum of appeal are true to the best of my/ our knowledge and belief and that nothing has been concealed or misrepresented therein. Further the tax admitted as due has been paid in the appropriate treasury/bank as per proof enclosed. Verified on this....day of....200. at ........ (Signature of applicant or his authorized representative) Acknowledgement Received from............memorandum of appeal with enclosures mentioned therein and ........ Seal of Office Date
