(See Rule 17(5A) of  A.P.G.S.T. Rules, 1957)
Statement of Particulars for the Purpose of Final Assessment

1. Name of the Dealer        :

2. Full Address                      :

3. A.P.G.S.T. R.C. No.                :

4. C.S.T. R.C. No.                         :

5. Assessment year                    :

6. Status of the dealer                 :

7. Name(s) of the Proprietor,                           :

    Mg. Director, all Partners, etc.






8. Period of business during the                      :

    assessment year


9. Addresses of branches and                         :
godowns within the State







10. Addresses of branches outside the State        :








11. Address of factories within the State                           :







12. Address of factories outside the State        :






13. Details of books of account maintained         :

      (Specify whether computerized)


14. Enclose Trading and Profit & Loss Account        :


15. Enclose Manufacturing Account                :


16. In the case of Sec.5E transactions, enclose                

      copies of agreements applicable for the  :

       year along with the list of  lessees and the
  amounts received.


17. In the case of Sec.5F/5G transactions      :
       enclose copies of agreements and the list
       of contracts executed during the year with
       the amounts received from each contractee.


18. In the case of Tax Deduction at Source,             :
     enclosed a statement showing the deductions
     made, along with the certificates of deduction
     issued by the contractees in original.


19. Whether the assessee deducted tax                    :
      under Sec.5H, if not reasons, therefor.


20. If the assessee deducted the tax for the        :
     contracts done to him under Sec.5H,
     enclose the list showing the deductions made
     and me payments made to the Government.


21. Registration particulars under Sec.5B :


22. Particulars of L1 obtained for the year.     :


23. Number of Waybills obtained in the year      :


24. Number of forms obtained in the year            :


a)       C declaration forms under the CST Act            :


b)       F declaration forms under the CST Act            :


c)       H declaration forms under the CST Act            :


d)       G declaration forms under the APGST            :



25. Total amount of APGST collected in the year            :


26. Total amount of CST collected in the year     :


27. Details of industrial incentives i.e. Eligibility      :
      certificate numbers and dates in respect
      of Tax deferment and Tax exemption.
      (Furnish separate statement showing the
 eligibility and availment, certificate-wise).


28.Dates of inspection of the business                     :

      premises/ factory premises by the

     Officers of C.T. Department and

      Vigilance and Enforcement Wing.


29.Furnish statement showing the payment     :

      of Compounding fee and penalty, if any.


30. Are all the purchases covered by invoices.      :


31. Are bills issued for the sale of goods.  :


32. Quantity and value of Diesel Oil purchased         :
       at concessional rate for use in captive
        power generation.

33. Total number of units of power generated          :
        through captive power generation.

34. Total number of declaration forms used     :
      in the year.

a) C forms under the CST Act    :

b) El forms under the CST Act    :

c) EII forms under the CST Act    :

d) F forms under the CST Act    :

e) G forms under the APGST Act              :

f)  H forms under the CST Act    :


35. Payment particulars of Registration fee. :


36. Enclose A.R.I, II, III and IV Statements.      :


Signature:                                                                                                 Signature of the Dealer

Name of the Ch. Acct.                                                                            Designation

Membership No.