Form of Declaration by a Resident Principal
[See Rule 17C of A.P.G.S.T. Rules, 1957]


Sri / M/s.

I/We hereby declare that on the goods detailed in the Statement below which are entrusted to you for sale, the tax due at the point of first sale/first purchase has been paid or/is payable by me or is payable by Sri/Messers _______________________________________________________________________ being the dealer who purchased them for me.



Serial No.

Date of entrustment of goods

Name and Quantity of each of the goods (in metric weight)

No. of items entrusted

Value of each of the goods

If covered by any invoice No. or Patti No. and date


























































Declaration :

I/We hereby declare that to the best of my/our knowledge and belief, the information furnished in the above Statement is true and correct.

  Place:                                                                                            Signature of the Principal __________________________

Date:                                                                                              Address ______________ _____________


1.In respect of any of the goods or a part of which tax paid, or liability of tax was owned, separate declarations should be furnished for that part of the goods and the rest of the goods. 

2.In the case of dealings in paddy, rice and jowar, (including their containers), involving initial purchases from several persons, the dealers to whom they have been entrusted by another dealer for sale need only set out the particulars of the immediate dealer (Name, Address, Registration Number and date of transaction) from whom he had obtained them instead of the name of the persons from whom the goods were initially purchased.