FORM XII - A Statement of Claim for Refund of Tax paid on sales or purchases of Declared Goods (See Rule - 42-A) To ........ Circle The Assistant Sales Tax Officer, Sales Tax Officer, I......... Proprietor/ partner/ manager/ principal officer (authorised departmental) of the business known as ...... bearing Registration Certificate number ....... whose only / chief place of business in the district of ..... is situated at ...... P.O.......... pray for refund under the provisions of rule 42-A of the Orissa Sales Tax Rules, 1947 in respect of goods, the particulars of which are given below. The amount may be made payable at the Treasury / Sub-treasury at............ 1. Serial Number. 2. Date of payment of tax in respect of the goods under section 5 of the Act, number and date of Treasury Challan by which tax was paid into the Treasury or number and date of money order or bank draft thereof. 3. Description of the goods. 4. Quarter in which the sale or purchase was included in the turnover. 5. Amount of tax paid under section 5 of the Act. 6. By whom sold in the course of inter-State trade or commence. 7. Quarter in which the sale was included in the turnover of the dealer against column 6 and tax paid. 8. The name and address of the dealers, if any who bought and sold the goods to the dealer specified in column (6) I ...... the applicant named above do hereby declare that what is stated above is true to the best of my knowledge and belief and also further declare that the amount of refund claimed above has been paid to Government and was not claimed earlier. Signature
