1. Name and Designation of the appellant	Name:
	Designation
	Jurisdiction
	State/Center-
	Name of the State:
2. GSTIN/ Temporary ID /UIN-
3. Appellate Order no.	Date-
4. Designation and Address of the Appellate Authority 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 demanded, disputed and admitted:

 

Particulars of demand, 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					< total >
		e) Other					< total >
		charges
	Amount under dispute (B)	a) Tax/ Cess					< total >	< total >
		b) Interest					< total >
		c) Penalty					< total >
		d) Fees					< total >
		e) Other charges					< total >

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 Officer:
	Designation:
	Jurisdiction:-