Form GST APL-05

See rule 110(1)

Appeal to the Goods and Services Tax Appellate Tribunal

1. GSTIN/Temporary ID/UIN –

2. Name of the appellant –

3. Address of the appellant –

4. Respondent(s):

(a)

(b)

(c)

..............

(Specify designation and office of the respondent(s))

5. Details of the authorised representative of the applicant:

(a) Name…………………. Mobile ………………… Email ………………….

(b) Name…………………. Mobile ………………… Email ………………….

…………………………………………………………………………………………………..

6. Order appealed against - APL-04/Rejected APL-02 Number -Date-

7. Is place of supply involved in the dispute – Yes/No

8. Designation and Office of the Appellate Authority/Revisional Authority passing the order appealed against -

9. Date of communication of the order appealed against –

10. Details of order challenged before Appellate authority/Revisional Authority:

a) Number - Date –

b) Order type (As per Annexure A)

c) Period of dispute from (DDMMYYYY) To (DDMMYYY) (Applicable for demand related orders)

11. Details of the authority passing the order specified at Sl. no. 9: (Specify designation and Office of the said authority)

12. Name of the authorized representative

(a) Name…………………. Mobile ………………… Email ………………….

(b) Name…………………. Mobile ………………… Email ………………….

…………………………………………………………………………………………………..

13. Act (CGST/ SGST/ IGST/ Cess)

14. Details of the case under dispute:

a) Brief issue of the case under dispute

b) Category of case under dispute (As per Annexure B)

c) Market value of goods, where goods have been seized

15. Case Summary (As per Annexure C)

16. About Appellant (As per Annexure D)

17. Statement of facts (As per Annexure E)

18. Grounds of appeal

19. Prayer

20. Details of demand created, disputed and admitted.

21. Details of payment of admitted amount and pre-deposit:

(a) Details of amount payable:

(b) Details of payment of admitted amount and pre-deposit (pre-deposit 10% of the disputed admitted tax and cess)

(c) Interest, penalty, late fee and any other amount payable and paid:

Verification

I, < ______________________________ >, hereby solemnly affirm and declare that the information given hereinabove is true and correct to the best of my knowledge and belief and the same is derived from information, documents and records in my possession and further that nothing has been concealed therefrom. I further declare that no appeal against the impugned order has been preferred by me or my behalf before any Court or Authority or is pending before any Court or Authority.

Verified today, the _____________________________________ day of ______________month______________ 20...__________

< Signature>

Place:

Name of the Applicant

Date: Designation/Status

Annexure A

(Order Type )

Annexure B

(Category of case under dispute or issues involved )

Annexure C

Case Summary (indicate Amount in INR, wherever quantified and wherever applicable, Not exceeding 1000 characters in each cell)

User can add more than one Issue

Annexure D

About Appellant

Appellant to state in free text form as follows:

Appellant to mention:

(a). his constitution of business (e.g. Company, Partnership, HUF, Trust, etc.)

(b). Statute under which incorporated, if any (e.g. Companies Act, Trust Act, Societies Registration Act, etc.)

(c). date of its constitution

(d). constitution/identification number assigned to it by constituting authority (e.g. Corporate Identification Number in case of a company, etc.)

(e). Address of its Head Office and address of its principal place of business in State

(f). GSTIN/Temp Id and date from which registered under GST

(g). Nature of the business in which he/it is engaged (e.g. manufacturer /wholesaler /retailer / supplier of services, etc.)

(h). Any other relevant fact in view of the appellant”

Annexure E

Statement of Facts (Case History)

(indicate Amount in INR, wherever quantified and wherever applicable, not exceeding 1000 characters in each cell, Upload documents if necessary)