ANNEXURE 67
- Document type
- Manual
- Dated
- Category
- Central Excise Manual
FORM - R
FORM - R
Application for refund of excise duty
[(Rule 173-S)]
To,
The Assistant Commissioner,
Central Excise,
Division ________________________
Collectorate ____________________
1. I/we claim refund of Rs. _______________________________________________________ (Rupees ___________________) on the grounds mentioned hereunder:-
(a)
(b)
(c)
2. I/ We enclosed the following documents in support of the claim.
1.
2.
3.
4.
5.
3. The amount claimed was originally paid by AR1/AR5/AR6/AR7/AR8/AR9/AR10/DD1/DD2 Treasury Challan No. ______________ dated ______________ deposited into _________ Treasury under the Head of Account III- Union Excise duties / Duty on __________________ miscellaneous receipts / by adjustmnet in account current No. _____________ dated ___________.
The amount claimed was debited to account current No. ___________ on __________ against G.P. 1 No. ______________ dated ___________ vide entry at Serial No. __________________.
4. The amount claimed was paid vide G. P. 1. No. ___________ dated _________ and invoice No. ______________ dated of M/s. _____________.
5. The payment of refund may please be made in my/our favour by a crossed cheque on _________ Treasury / by money order at Government cost.
6. I/we declare that no refund on this account has been claimed / received by me / us earlier.
7. I/We declare that the duty for which refund has been claimed has not been charged / realised from any other person and a copy of the price-list, relevant Gate Pass (Central Excise) like documents and invoices are enclsed.
8. I/We undertake to refund on demand being made within six months of the date of payment of any rebate erroneously paid to me/ us.
9. I/we declare that the goods received by me/us after payment of Central Excise duty for which refund has been claimed has been consumed by me/us as industrial consumer / has been sold in wholesale / retail.
| Dated ___________________ Received payment Revenue Stamp (For amounts exceeding Rs. 20.00) | Signature and full address of claimant Signature of claimant |
Claim of Shri/ Messrs_______________________________ has been scrutinised and found correct.
Refund of Rs. ____________________ (Rupees ________________) is sanctioned.
Certified that no refund order regarding the sum now in question has previously been passed.
Head of Account
Supdt. /A.C., of C. Ex. ___________
(SANCTIONING AUTHORITY)
Cheque No. ______________ dated _______________ for Rs. __________________ (Rupees ________________________) issued on ___________________ (RBI/SBI/Treasury) in settlement of this claim.
AC of Central Excise _______________
(For use in the CA. O. s office)
(a) DD1/ DD2/ AR1/AR5/AR6/ AR7/AR8/AR9/AR10/T.C. No. _______________ dated ________________ Gate Pass No. _______________
(b) Debit entry in account current No. __________________ dated ___________ and (ii) Refund has been noted against the original credit under my signature.