You are hereby directed to make the 
		payment by <Date>  failing which proceedings shall be initiated 
		against you to recover the outstanding dues.
		Signature                              
		
		Name                                  
		
		Designation                          
		
		Jurisdiction                           
		
		Address                               
		
		 To 
		_______________ (GSTIN/ID) 
		----------------------------Name
 _______________ (Address )
		Note -
		1. Only applicable fields may be filled up. 
		2. Column nos. 2, 3, 4 and 5 of the Table at serial no. 5 i.e. tax rate, 
		turnover and tax period are not mandatory. 
		3. Place of Supply (POS) details shall be required only if the demand is 
		created under the IGST Act.”.