Form St-4 - Form Of Appeal To The Commissioner Of Central Excise (Appeals)

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FORM ST-4
Form of Appeal to the Commissioner of Central Excise (Appeals) under section 85 of the Finance Act,1994 (32 of 1994)
:
1.
No.__________of______20___
2.
Name and address of the appellant
:
Designation and address of the officer passing the decision
3.
:
or order appealed against and the date of decision or order
Date of communication of the decision or order appealed
4.
:
against to the appellant
5.
Address to which notices may be sent to appellant
:
:
5A.
(i)
Period of dispute
Amount of service tax, if any, demanded for the period
(ii)
:
mentioned in column (i)
Amount of refund, if any, claimed for the period
:
(iii)
mentioned in column (i)
(iv)
Amount of interest
:
(v)
Amount of penalty
:
Value of the taxable service for the period mentioned
(vi)
:
in column (i)
Whether service tax or penalty or interest or all the three
6.
:
have been deposited?
6A.
Whether the appellant wishes to be heard in person?
:
7.
Relief claimed in appeal
:
STATEMENT OF FACTS
Grounds of appeal
Signature of the authorised
Signature of the
representative, if any
appellant
Verification
I,______________________ the appellant, do hereby declare that what is stated above is true to the best of my information and
belief.
Verified today, the ____________________ day of ___________
Place:
Date :
Signature of the authorised
Signature of the appellant
representative, if any
or his authorised representative
Note :- The form of appeal including the statement of facts and the grounds of appeal shall be filed in duplicate and shall be
accompanied by a copy of the decision or order appealed against.

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