FORM 22 [See rules 11(5) and 25(2)] Refund Adjustment Order Name and address of the assessee ........... Registration Certificate No. under the Goa Tax on Entry of Goods Act, 2000 ............... (1) Certified with reference to the assessment record of the assessee for the period from ... to ... a refund of Rs... (figures) Rupees ............ (in words) is due. (2) Certified that the amount concerning which this refund is allowed has been credited to the treasury. (3) Certified that no refund payment order/refund adjustment order regarding the sum in question has previously been granted and that this order of refund adjustment has been entered in the original file of assessment under my signature. (4) This refund is adjusted towards the amount of ..... due from the said refund for the period from ... to .... Place: Signature Date : Designation, Asst./Entry Tax Officer
