Form GST APL – 05
 [See rule 110(1)]

Appeal to the Appellate Tribunal

1. GSTIN/ Temporary ID /UIN -
2. Name of the appellant -
3. Address of the appellant –
4. Order appealed against-                                                                                                                     Number-                                                             Date
5.Name and Address of the Authority passing the order appealed against -
6. Date of communication of the order appealed against -
7. Name of the representative -
8. 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        

(v) Market value of seized goods

9. Whether the appellant wishes to be heard in person?
10. Statement of facts
11. Grounds of appeal
12. Prayer

13. Details of demand created, disputed and admitted

Particulars of demand Particulars Central tax State/ UT tax Integrated tax Cess Total amount
Amount
demanded/
rejected >,
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 >
Amount admitted (C) a) Tax/ Cess         < total > < total >
b) Interest < total >
c) Penalty < total >
d) Fees < total >
e) Other charges < total >

14. Details of payment of admitted amount and pre-deposit:
    (a) Details of amount payable :

Particulars   Central tax State/ UT tax Integrated tax Cess Total amount
 

a) Admitted amount

 Tax/ Cess         < total > < total >
Interest < total >
Penalty < total >
Fees
Other charges < total >
< total >

b) Pre-deposit (20% of disputed tax/cess but not exceeding Rs.50 crore each in respect of CGST, SGST or cess or not exceeding Rs.100 crore in respect of IGST and Rs.50 crore in respect of cess)

 Tax/ Cess < total >

 

(b) Details of payment of admitted amount and pre-deposit (pre-deposit of 20% of the disputed tax and cess but not exceeding Rs. 50 crore each in respect of CGST, SGST or cess or not exceeding Rs.100 crore in respect of IGST and Rs. 50 crore in respect of cess)

Sr. No Description Tax payable Paid through Cash/ Credit Ledger Debit entry no. Amount of tax paid
          Integrated tax Central tax State/UT tax CESS
1 2 3 4 5 6 7 8 9
1. Integrated tax   Cash Ledger          
Credit Ledger          
2. Central tax   Cash Ledger          
Credit Ledger          
3. State/UT tax   Cash Ledger          
Credit Ledger          
4. CESS   Cash Ledger          
Credit Ledger          

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

Sr. No. Description Amount payable Debit entry no. Amount paid
Integrated tax Central tax State/UT tax CESS Integrated tax Central tax State/UT tax CESS
1 2 3 4 5 6 7 8 9 10 11
1. Interest                  
2. Penalty                  
3. Late fee                  
4. Others (specify)                  

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 nothing has been concealed therefrom.

Place:
Date:

< Signature>
Name of the Applicant:
Designation /Status:

15. Place of supply wise details of the integrated tax paid (admitted amount only) mentioned in the Table in sub-clause (a) of clause 14 (item (a)), if any

Place of Supply (Name of State/UT) Demand  Tax  Interest  Penalty  Other Total  
1 2 3 4 5 6  7”
  Admitted amount [in the Table in sub-clause (a) of clause 14 (item (a))]