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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___

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2.

Name and address of the appellant

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3.

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

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4.

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

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5.

Address to which notices may be sent to appellant

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5A.

(i)

Period of dispute

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(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)

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6.

Whether service tax or penalty or interest or all the three have been deposited?

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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†
representative, if any

Signature of t

 

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