FORM VAT - XVII (See rule 32) M/s......... Appellant ......... Versus The Appropriate Assessing Authority/Appellate Authority Respondent (2) Style of business : (3) Status of the business (write here individual, HUF Partnership, Limited Company, Association of : persons, etc as the case may be) (4) Location of principal place of business : (5) Address to which notice may be sent to the appellant : (6) Name of the Appropriate Assessing Authority/Appellate Authority passing the order : (7) Period to which the appeal relates : (8) Date of order : (9) Date of service of order appealed against : (10) Amount demanded Tax : Penalty : Interest : Total : (11) Amount paid Tax : Penalty : Interest : Total : (12) Amount in dispute Tax Penalty Interest Total : : : : (13) Relief claimed in appeal : Memorandum of appeal to the Appellate Authority/Tribunal under section 35/36 of the Goa Value Added Tax Act, 2005 (Act 9 of 2005) Before the Appellate Authority/Tribunal No....of ...20.. (To be filled in by the office of the Appellant Authority/Tribunal) (14) The appellant has paid the tax assessed, interest levied and penalty imposed under the order appealed against as shown below : (15) A Certified copy of the order appealed against is attached (16) Grounds of appeal (may be recorded in a separate sheet if the space is insufficient) Amount paid before assessment Paid after assessment/appeal Balance due, if any, at the time of filing of appeal Amount Amount Treasury Receipt No. Date (i) Out of admitted tax, interest & penalty (ii) Out of disputed tax, interest & penalty Verification I/ We ....the appellant (s) do hereby declare to the best of his/their knowledge and belief that the facts set out in the memorandum are true and that the amount of tax assessed or reassessed interest and the penalty, if any, imposed or the tax and penalty admitted to be due has been paid by Treasury Chalan dtd....,copy of which is enclosed. Date: Signature of appellant or person Place: duly authorised in writing in his behalf by the appellant. For use in the office of the Appellant Authority/Tribunal. Date of receipt...... ....................................... Acknowledgment Received from M/s ..........of ....TIN. (if any)....... Memorandum of Appeal alongwith the enclosures mentioned therein. Place: Signature of receiving Date: Official (Office Seal) .......................................
