(See Rule 33(2)(iv) of A.P.G.S.T. Rules, 1957)

The Appellate Deputy Commissioner


I/We,___________________________________________________________Son/Daughter/Wife of ____________________________________________________ appellant is named in the appeal preferred herein as____________________________________________________________(Dealer Name/Firm Name), an assessee on 
the rolls of ______________________with Registration Number ___________________________________ hereby declare 
that the tax admitted to be due, or of such instalments as have been granted have been paid, for the relevant assessment year, in respect of which the appeal is preferred, the details of which are given below.  I hereby declare that no arrears are
due from me the above-mentioned firm for the relevant year for which appeal is preferred.


1.       Total Tax paid:

             a)  Cheque/DD particulars

Number      :                                                     Date :

                       Bank      :                                                           Branch :

    b) Cash (Receipt No.) if paid

                                 Receipt No.:                                                            Date:

            c) Challan particulars:

                       Number      :                                                           Date:
                          Name of Treasury      :



                                                                                                                                                                       Status and  relationship to thedealer