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Form 17-A
( See rule 21-A)
Memorandum of revision |
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To,
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I, hereby apply for
revision and furnish the necessary particulars:
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[1] |
Registration certificate No. |
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[2] |
Name of the employer/ person |
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[3] |
Address |
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[4] |
Style of Profession / Trade /
calling |
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[5] |
Period involved under impugned
order against which revision is preferred |
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[6] |
Name of the authority who passed
the impugned order |
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[7] |
Date of order |
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[8] |
Date of service of order |
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[9] |
Amount demanded |
(1) |
Tax |
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(2) |
Penalty |
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Total |
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[10] |
Amount of admitted tax |
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[11] |
Amount paid |
(1) |
Tax |
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(2) |
Penalty |
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Total |
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[12] |
Amount in dispute |
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[13] |
Grounds on which revision has been
preferred |
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A certified copy of the impugned
order and a copy of Challan in proof of payment of tax/
penalty are enclosed. |
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The above statements are true to
the best of my knowledge and belief. |
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Place
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Signature
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Date
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Status
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