DECLARATION [second proviso to section 54(3)]

I hereby declare that the goods exported are not subject to any export duty. I also declare that I have not availed any drawback of central excise duty/service tax/central tax on goods or services or both and that I have not claimed refund of the integrated tax paid on supplies in respect of which refund is claimed.

Signature 
Name ' 
Designation / Status"]

DECLARATION [section 54(3)(ii)]

I hereby declare that the refund of input tax credit claimed in the application does not include ITC availed  on goods or services used for making 'nil' rated or fully exempt supplies.

Signature

Name '

Designation / Status

“DECLARATION [rule 89(2)(f)]

I hereby declare that tax has not been collected from the Special Economic Zone unit /the Special Economic Zone developer in respect of supply of goods or services or both covered under this refund claim.
Signature
Name –
Designation / Status”.

DECLARATION [rule 89(2)(g)]

(For recipient/supplier of deemed export)

In case refund claimed by recipient □

I hereby declare that the refund has been claimed only for those invoices which have been detailed in statement 5B for the tax period for which refund is being claimed and the amount does not exceed the amount of input tax credit availed in the valid return filed for the said tax period.I also declare that the supplier has not claimed refund with respect to the said supplies.  

In case refund claimed by supplier □

I hereby declare that the refund has been claimed only for those invoices which have been detailed in statement 5B for the tax period for which refund is being claimed and the recipient shall not claim any refund with respect of the said supplies and also, the recipient has not availed any input tax credit on such supplies.

Signature

Name '

Designation / Status

UNDERTAKING

I hereby undertake to pay back to the Government the amount of refund sanctioned along with interest in case it is found subsequently that the requirements of clause (c) of sub-section (2) of section 16 read with sub-section (2) of section 42 of the CGST/SGST Act have not been complied with in respect of the amount refunded.   

Signature

Name-

Designation / Status';

SELF-DECLARATION [rule 89(2)(l)]

I/We                             (Applicant) having GSTIN/ temporary Id -------, solemnly affirm and certify that in respect of the refund amounting to Rs. ---/ with respect to the tax, interest, or any other amount for the period from---to----, claimed in the refund application, the incidence of such tax and interest has not been passed on to any other person. 

Signature

Name '

Designation / Status

(This Declaration is not required to be furnished by applicants, who are claiming refund under clause (a) or clause (b) or clause (c) or clause (d) or clause (f) of sub-section (8) of section 54.)

I/We hereby solemnly affirm and declare that the information given herein above is true and correct to the best of my/our knowledge and belief and nothing has been concealed therefrom.  

                                  I/We declare that no refund on this account has been received by me/us earlier. 

Place

Signature of Authorised Signatory

Date

(Name)

Designation/ Status

';

Invoice details

Integrated tax

No.

Date

Invoice details

Goods/ Services (G/S)

Shipping bill/ Bill of export

EGM Details

Tax paid

Order  Date:
(Amount in Rs.)

Recipient‘s GSTIN/ UIN Name (in case B2C)

Invoice details

Details of tax paid on transaction considered as intra –State / inter-State transaction earlier

Taxes re-assessed on transaction which were held inter State / intra-State supply subsequently

1.