1.

No. ..................... of.................. 2006

2.

Name and address of the appellant.

3.

Designation and address of the officer passing the decision or order appealed against and the date of the decision or order.

4.

Date of communication of the decision or order appealed against to the appellant.

5.

Address to which notices may be sent to the appellant.

(i) Description and classification of goods

(ii) Period of dispute

(iii) Amount of duty, if any, demanded for the period mentioned in
item (ii)  

(iv) Amount of refund if any claimed for the period mentioned in
item (i)  

(v) Amount of fine imposed

(vi) Amount of penalty imposed

(vii) Market value of seized goods.

7.

Whether duty or penalty or both is deposited; if not whether any application for dispensing with such deposit has been made. (A copy of the challan under which the deposit is made shall be furnished).

8.

Whether the appellant wishes to be heard in person ?

9.

Reliefs claimed in appeal.

Signature of the authorized

Representative, if any

Signature of the applicant.

Signature of the authorized

Representative, if any

Signature of the applicant.

Note : (1)

The grounds of appeal and the form of verification shall be signed by the appellant in accordance with the provisions of
rule 3.

(2)

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.