Form GST APL - 03
[See rule 109(1)]

Application to the Appellate Authority under sub-section (2) of Section 107

1. Name and designation of the appellant                                                              Name-

                                                                                                                        Designation-

                                                                                                                        Jurisdiction-

                                                                                                                        State/Center-

                                                                                                                        Name of the State-

2. GSTIN/ Temporary ID /UIN-

3. Order no. Date

4. Designation and address of the officer passing the order appealed against

5. Date of communication of the order appealed against

6. Details of the case under dispute-

    (i) Brief issue of the case under dispute-
    (ii) Description and classification of goods/ services in dispute-
    (iii) Period of dispute-
    (iv) Amount under dispute

Description Central tax State/ UT tax Integrated tax Cess
a) Tax/ Cess        
b) Interest        
c) Penalty        
d) Fees        
e) Other charges        


7. Statement of facts
8.Grounds of appeal
9.Prayer

10. Amount of demand in dispute, if any -

Particulars of demand/refund, if any

 Particulars Central tax State/UT tax Integrated tax Cess Total amount
Amount of demand created, if any (A) a) Tax/ Cess         < total > < total >
b) Interest < total >
c) Penalty < total >
d) Fees
e) Other charges < total >
< total >
Amount under dispute (B) a) Tax/ Cess         < total > < total >

 
b) Interest < total >
c) Penalty < total >
d) Fees < total >
e) Other charges < total >

Place:
Date:

<Signature>

Name of the Applicant Officer:    
Designation:                             
Jurisdiction: