Form VAT - XII [See rule 30(1) of the Goa Value Added Tax Rules, 2005] REFUND VOUCHER Voucher No.......... Refund Voucher for the refund of tax and/or penalty and/or interest Under the Goa Value Added Tax Act, 2005(Act 9 of 2005). Treasury/Sub-Treasury Payable at the....... State Bank of India (Branch) __________________ for Rs........ (in figures) _______________ (in words) for being credited to the Bank Account of the dealer under no...... at........... within three months of the date of issue. (Bank & Branch) To, The Treasury/Sub-Treasury Officer, The Agent or Manager of State Bank of India ________________ (1) Certified that with reference to the assessment record of ................ (issued by the Commercial Taxes Office of ..........Ward), for the period from ......to....., a refund of Rs. .............is due to .................. (2) Certified that the amount of tax and/or penalty and/or interest concerning which this refund is allowed has been duly credited to the Government Treasury. (3) Certified that the refund amount shall be debited to the following number of Accounts: ........ ........ ......... (4) Certified that no refund order regarding the sum now in question has been previously been granted and this order of refund has been entered in the original file of assessment under my signature . (5) Please pay to ............the sum of Rs.......(in figures) Rupees .................................(in words) Date: (Signed) .......... (Seal Assessing Authority) Designation......... Treasury/Sub-Treasury Date of encashment in the State Bank of India __________________ Date...... Place..... Pay Rupees ...........................only Treasury/Sub-Treasury The ...20 ... Officer-in-charge of State Bank of India __________________ Received payment......... Claimant's Signature.... Examined, Accountant......... (a) Classification: Tax.... Penalty... Interest.... Third copy of the Refund Voucher is identical with the second copy and it is not reproduced here.
