FORM XV(See Rule 29)Claim for Refund

1.       Name of the Claimant                 :            

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 ordered.          :

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

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

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

 (iii) Date on which notice of finalassessment and order of refundwas served on the dealer.                          :

 (iv)    Amount of refund due.                :

                    Signature of the Claimant.

                                                    Signature of the Authorised Representative, if any;

VERIFICATION   

I/We _______________________________________________________________ the claimant(s) do hereby 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.