FORM R Application for Registration as a Tobacconist under Section 4A of the Andhra Pradesh Tax on Luxuries Act

FORM R

Application for Registration as a Tobacconist under Section 4A of the
Andhra Pradesh Tax on Luxuries Act, 1987
(See Rule 4A)

The Assistant/Deputy Commercial Tax Officer,
______________________________________
______________________________________
______________________________________

Division____________________________ Circle_______________________Unit______________

I_____________________________________________________________________ (Name of the Tobacconist) carrying on the proprietary business known as_______________________________________________________________________ (Name of the Tobacconist) here by apply for registering me under Section 4A of the Andhra Pradesh Tax on Luxuries Act,1987.

I____________________________________________________________________(Name of the Tobacconist) the_______________________________________**(Status of applicant in the firm) of the _________________________________________________________ ***(Status of firm)carrying on the business known as __________________________________________(Name of the Tobacconist) here by apply for registering, the said _________________________________________________________________ ***(Status of firm)

Under Section 4A of the Andhra Pradesh Tax on Luxuries Act, 1987.

***Status of applicant in firm may be.

1. Partner

2. Managing Director

3. Secretary

4. Principal Officer

5. Trustee and

6. Any other status

**Status of firm may be.

1. Partnership

2. Private Ltd.,

3. Public Ltd.,

4. Society

5. Trust

6. Club

7. Association

8. Govt. Company

9. Hindu Undivided Family

The particulars of the above business are given below:

1.Name and full postal address of the principal place of tobacconist with the particulars of building name and number, ward name and number, road name, street name etc.

Name :

Address :

Building Name : Building Number:

Ward Name : Ward Number :

Street/Road :

Village/Town : District :

State : Pin code :

2.Name and full postal address of all the other places of tobacconist in the State with particulars of building, name and number ward name and number, road name, Street etc., of each place of tobacconist (if the space in this column is found to be insufficient additional sheets may be used and duly signed)

Name :

Address :

Building Name : Building Number:

Ward Name : Ward Number :

Street/Road :

Village/Town : District :

State : Pin code :

Page Numbers of additional sheet(s) used_____________________

3. (a) Name and full address of all the other places of business outside the State with full details as required under Column 2. (Attach additional sheets if required).

Name :

Address :

Building Name : Building Number:

Ward Name : Ward Number :

Street/Road :

Village/Town : District :

State : Pin code :

(b) Name and full address of registered office of business, if situated outside the State of Andhra
Pradesh along with Registration Certificate Number:

Name :

Address :

Building Name : Building Number:

Ward Name : Ward Number :

Street/Road :

Village/Town : District :

State : Pin code :

Page Number(s) of additional sheet(s) used______________

4. Complete list of godowns in which the goods relating to the tobacconist are stored and address of every such godown (Attach additional sheets in the given format, if required)

Name :

Address :

Building Name : Building Number:

Ward Name : Ward Number :

Street/Road :

Village/Town : District :

State : Pin code :

Page Numbers(s) of additional sheet(s) used ___________

5 Description of all classes of goods either bought, sold, manufactured, supplied, distributed etc, by the tobacconist (Attach additional sheets if required)

Sl. No.	Commodity Description	Code	Sl No.	Commodity Description	Code
1			6
2			7
3			8
4			9
5			10

Page Numbers of additional sheets used_____________

6 Date of commencement of Date Month Year
Business :

7 The language in which the Accounts are kept and maintained___________________________________From_____________________________To___________________

8 The accounting year followed by the tobacconist for the purpose of Income Tax Act ____________________________________ (State month or Festival)

9 Name(s) and Address(s) of the proprietors, partners, members, all persons having any interest in the business (additional sheet with the following columns shall be used, if necessary)

Page Number(s) of additional sheet(s) used________________________

a) Serial Number :

b) Name in full of the person :

c) Name of father of the person :

d) Age of the person :

e) Permanent address of the person :

f) Present postal address of the person :

g) Extent of interest of the person :

h) Signature of the person :

i) Name, address and signature of witness attesting signature and identifying the persons. (The identification should be by 2 dealers who are registered under the Act)

a) Partners names & Signatures.

Sl.No.	Name	Signature
1.
2.
3.
4.
5.
6.
7.
8.

Witness (Registered Tobacconist)

Sl.No.

Name & Address

RC.No.

Signature

10 Particulars of other interests, if any, in other business concerns or other concerns, such as shares and stocks, investment in chit funds, securities, defence, certificates National Savings Certificates, Central and State loans including those floated by Public undertakings, deposits including Bank Accounts and movable and immovable properties of partners, members in the business, both in State and in other States (Please append a list containing these particulars, in respect of each member).

11 Particulars of registration certificate, if any, held by the tobacconist before the submission of this application under the A.P. Luxuries Tax Act, with the name of the office from where the certificate has been obtained with number and date of certificate.

Date of Issue.____________________

        Divn.___________________________

        Circle___________________________

        Unit_____________No_____________

Date____________________________

12 The total turnover of Receipts
the year preceding to which
the application is submitted. :

13 Actual turnover of receipts of
the year upto date of submission
of the application. :

14 The estimated total turnover of
receipts for the year in which
application is submitted :

15 Amount of registration fee paid
with particulars of challan number
and date cheque number and date,
name of treasury, bank etc. :

DECLARATION

I,_____________________________________________________________ Son/Daughter/Wife of ________________________________________________ hereby declare that to the best of my knowledge and belief the information in this application given above is true and correct.

Place :

Name, address and Signature of the person Signing
Date : With the status and relationship to the tobacconist

(FOR OFFICIAL USE BY THE REGISTERING AUTHORITY)

1.	Date of receipt of application	:
2.	Nature of order passed by the Registering Authority in the Application.	:
3.	Date on which, the place at which and the officer before whom the applicant is called for verification accounts.	Date : Place:
4.	The date by which the registration certificate is ready.	:
5.	Registration Certificate Number & Date of issue.	:
6.	Old Number (if any) in the Red Ink.	:
7.	No. of Branches.	:
8.	No. of Godowns	:
9.	No. of Partners	:
10.	No. of Commodities	:
11.	General Category of Tobacconist	:

Signature of the Registering Authority

Additional sheet for point no. [2, 3(a), 3(b),4]. ________________

Name :

Address :

Building Name : Building Number:

Ward Name : Ward Number :

Street/Road :

Village/Town : District :

State : Pin code :

Name :

Address :

Building Name : Building Number:

Ward Name : Ward Number :

Street/Road :

Village/Town : District :

State : Pin code :

Name :

Address :

Building Name : Building Number:

Ward Name : Ward Number :

Street/Road :

Village/Town : District :

State : Pin code :

Name :

Address :

Building Name : Building Number:

Ward Name : Ward Number :

Street/Road :

Village/Town : District :

State : Pin code :

Additional Sheet for point No.5 :

Sl. No.	Commodity Description	Code

Sl. No	Name in full of the person	Father’s Name	Age	Permanent Addresses	Permanent Postal Addresses	Extent of Interest	Signature