FORM  XII(See Rules 21 & 22)Appeal/Revision application against an Order of Assessment Appeal Penalty Interest

To______________________________________________________________________________________________________

I hereby appeal / apply for revision and furnish the necessary particulars :(i)    Registration Certificate No.       : 

(ii)   Enrolment Certificate No            : 

(iii)  Name of the Employer and Status:(iv) Style of Professions, Trade,                      Calling, etc.                                             :

(v)  Location and address                :(vi) Period involved under impugned        orders against which Appeal /        Revision is preferred i.e.,            :                         from                                          to   

(vii)    (a)Name of the authority who          passed the impugned order              :

            (b) Date of passing of the                  impugned order                                :

           (c) Date of Service of                 Notice of Demand                                   :            (d) Amount of       (i)  Tax                      :

                                 (ii)  Penalty                :                                             (iii) Interest                 :                                            Total                        :

          (e) Amount of admitted Tax                          :         (f)  Amount paid      (i)  Tax                    :                                             (ii) Penalty              :                                             (iii) Interest             :          

      (g)  Amount in dispute                      :                        Grounds                                  :           (attach additional sheet if necessary)

The above statement is true to the best of my knowledge and belief and the tax, penalty and interest payable by me has been paid in full.

 Place:                                                               Signature:

 Date:                                                                Status     :

Note:

(1) The Appeal/Revision application accompanied by the order appealed/Revision against in original or by a certified copy thereof unless the omission to produce such order or copy is explained to the satisfaction of the appellate/revision authority.

(2)  The appeal/revision should be written in English and should setforth concisely and under distinct heads the grounds should be numbered consecutively. 

(3)   (i)    The appeal/revision shall be in duplicate    (ii)    The appeal shall be accompanied by a Treasury Challan in support of having paid the fee calculated at the Rate of 2% of the tax, penalty, or interest under dispute, subject to a minimum of Rs.50/- and maximum of Rs.1,000/-       

(iii)    An application for revision shall be accompanied by a Treasury Challan in support of having paid the fee calculated at the rate of 2% of the tax, penalty or interest under dispute, subject to a minimum of Rs.100/- and maximum of Rs.2,000/-