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
3.
Designation and address of the officer passing the decision or order appealed against and the date of 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 appellant
5A.
(i)
Period of dispute
(ii)
Amount of service tax, if any, demanded for the period mentioned in column (i)
(iii)
Amount of refund, if any, claimed for the period mentioned in column (i)
(iv)
Amount of interest
(v)
Amount of penalty
(vi)
Value of the taxable service for the period mentioned in column (i)
6.
Whether service tax or penalty or interest or all the three have been deposited?
6A.
Whether the appellant wishes to be heard in person?
7.
Relief claimed in appeal
STATEMENT OF FACTSGrounds of appeal
Signature of the authorised representative, if any
Signature of t