FORM XII Sales Tax Act, 1947 (See Rule - 39) 1. Period of assessment in respect of which refund is claimed. order of assessment reference. To Application Form for Refund of Tax under Section 14 of the Orissa I bearing Registration Certificate number whose only / chief place of business in the district of is situated at pray for refund of Rs. tax/ surcharge/penalty / security / interest paid by me. The refund may be paid in cash /by Refund Date on which 2. was passed Final order on 3. (i) Amount of (ii) Challan Number (iii) Date of payment 4. Amount as finally determined (Quote No. and date of order) 5. Amount of refund claimed. 6. Grounds for claiming refund. Signature /- Government of Orissa The Commissioner of Sales Tax. partner/ manager/ principal officer (authorised departmental)Proprietor/ of the business known as P.O being the amount of excess /-Rs. Adjustment Order payable at the Treasury / Sub-treasury. tax / surcharge / penalty paid ToFrom revisionappeal /-Rs. /-Rs. /-Rs. the applicant named above,I do hereby declare that what is stated herein is true to the best of my knowledge and belief, (and also further declare that the amount of refund claimed above has been paid by me that the amount or any part thereof has not been realized by me by way of tax or otherwise from any person or persons. Published on National Portal of India (india.gov.in) Department of Finance
