"Form GST APL-04 [See rules 109B, 113 (1) andl 15] SUMMARY OF THE DEMAND AFTER ISSUE OF ORDER BY THE APPELLATE AUTHORITY, REVISIONAL AUTHORITY, TRIBUNAL OR COURT Reference no. - Date - .
11'
4. GSTIN/ ID/UIN -
5. Name of the appellant/ person -
6. Address of the appellant / Temporary person- ,,
8. Order appealed against or intended to be revised -
9. Appeal no.
10. Personal Hearing -
11. Order in brief-
10. Status of order- Confirmed / Modified / Rejected
11. Amount of demand after appeal / revision:
Number Date- Date- Particul Central tax State / UT tax Integrated tax Cess Total ars Amou Detennin Amou Detennin Amou Detennin Amou Detennin Amou Detennin nt in ed nt in ed ntin ed nt in ed nt in ed disput Amount disput Amount disput Amount disput Amount disput Amount e/ e / el el e / earlier earlier earlier earlier earlier order order order order order 1 2 3 4 5 6 7 8 9 10 11 a) Tax '.
b) Interes t c) -~ Penalt " ,~,:
J y d) Fees e) Others ~tl f) ' Refun d
10. Place of supply wise details ofIGST demand Place of Supply Demand Tax Interest Penalty Other Total (Name of State / UT) ·~.
1 2 3 4 5 6 7 Amount in dispute / earlier order Determined Amount Place:
Date:
Signature:
Name of the Appellate Authority/ Revisional Authority/ Tribunal / Jurisdictional Officer Designation:
Jurisdiction: ,, No. GST/23/2017Nol-I f j<[ 7- Sd/- (Anirudh Singh) Commissioner of State Tax Dated Itanagar the 31st December, 2018 Copy to:- /rhe Secretary (Law & Judicial), Govt. of Arunachal Pradesh, Itanagar for information please.
2. The Director (Printing), Govt. of Arunachal Pradesh with a request to print 200 copies in the Extra Ordinary Gazette.
3. Office Copy.
~i:ud::t' Commissioner of State Tax Note:- The principal rules were published in the Gazette of Arunachal Pradesh, Extraordinary, No. 281 Vol. XXIV, Naharlagun, Monday, August 7, 2017, vide notification (APGST Rules, 2017), dated the 19th July, 2017, published vide file no. GST/23/2017, dated the 19th July, 2017 and last amended vide notification No. 46/2018 - State Tax, dated the 30th October, 2018, published vide file no. GST/23/2017 N ol-1, dated the 30th October, 2018.
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' Refund Type: On account of supplies made to SEZ unit or SEZ Developer ( on payment of tax) (Amount in Rs.)
GSTI Invoice details Shipping Integratede- Ces Integrat Integrat Net Nof bill/ Bill Tax s ed tax ed tax Integrat recipie of and cess and cess ed tax nt export/ involve involve and cess Endorse din din (8+9+1 d invoice '.;.::.'~ debit credit 0- 11) by SEZ note, if note, if No Dat Valu No Dat Taxab Am any any e e e le t.
Value 1 2 3 4 5 6 7 8 9 10 11 12 .• Statement-S [rule 89(2)(d) and 89(2)(e)J Refund Type: On account of supplies made to SEZ unit or SEZ Developer (without payment of tax) (Amount in Rs.)
Sr. No. Invoice details Goods/ Shipping bill/ Bill of export/ Services (G/S) Endorsed invoice no.
No. Date Value No. I Date 1 2 3 4 5 6 I 7 Statement-SA [rule 89(4)) Refund Type:On account of supplies made to SEZ unit / SEZ developer without payment of tax (accumulated ITC)- calculation of refund amount (Amount in Rs.)
Turnover of zero rated Net input tax Adjusted total Refund amount supply of goods and credit turnover (1 x273) services 1 2 3 4 - Statement SB [rule 89(2)(g)] Refund Type: On account of deemed exports SI. Details of invoices of outward Tax paid No. supplies in case refund is claimed by l" supplier/Details of invoices of inward (Amount in Rs) supplies in case refund is claimed by recipient GSTIN No. Date Taxabl&l Integrated Central State Tax /Union Cess of the Value Tax Tax Territory Tax supplier l 2 3 4 5 6 7 8 9 . _;.
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Statement-6 [rule 89(2)(j)} Refund Type: On account of change in POS (inter-State to intra-State and vice versa) Order Details (issued in pursuance of sections 77 ( 1) and (2), if any: Order No: Order Date: ·r (Amount in Rs.)
Recipien Invoice details Details of tax paid on Taxes re-assessed on t's transaction considered as intra transaction which were held GSTIN/ -State / inter-State transaction inter State / intra-State supply UIN earlier subseq uentl ,, Name Integrat Centr Stat Ces Place Integrat Centr Stat Ces Place (in case No Dat Yalu Taxab ed tax al tax el s of ed tax al tax el s of B2C) e e le UT Suppl UT Suppl Yalu tax y tax y e ~ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Statement-7 [rule 89(2)(k)} Refund Type: Excess payment of tax, if any in case of last return filed. Rs.) (Amount in Tax period ARN of Date of Tax Pavable return filing Integrated Central State/ Cess return tax tax UT tax 1 2 3 4 5 6 7 ;} Annexure-2 Certificate [rule 89(2)(m)) .t"~i' This is to certify that in respect of the refund amounting to Rs.<<>> -------------- (in words) claimed by M/s----------------- (Applicant's Name) GSTIN/ Temporary ID------- for the tax