(FORM XXIII)

Claim for Refund
(See Rule 44AA of A.P.G.S.T. Rules, 1957)

 

 

 

1.       Name of the dealer.

 

2.       If refund is sought in pursuance of an order of assessment.

 

(i)       No. and date of order of assessment.

(ii)     Date of notice of final assessment and refund order.

(iii)    Date on which the notice of final assessment and refund order was served on the dealer.

(iv)    Amount of refund order.

 

3.       If refund is sought in pursuance of an order passed in appeal or revision.

 

(i)      No. and date of order of the appellate of revisional authority.

(ii)     Date of revised notice of final assessment and order of refund.

(iii)    Date on which the notice of final assessment and order of refund was served on the dealer.

(iv)    Amount of refund due.

 

 

  

                                                                                                                    Signature of claimant.

 

                                                                                                         Signature of the Authorised Representative if any.

 

 


VERIFICATION

I/We____________________________________________________________________the claimant(s) do hereby be declare that
 what is stated herein is true to the best of my/our knowledge and belief.

 Verified today the _________________ day of _______________________________ 20 ______ 

 

                                                                                                                                            Signature of the claimant. 
   
                                                                                             
                                                                                                 Signature of the Authorised Representative, if any.


Note:This should be accompanied by the order of assessing, appellate or revisional authority in pursuance of which the claim is preferred.