CGST FORMS
APPEAL AND REVISION

Body

Form GST APL-04

[See rules 109B, 113 (1) and115 ]

SUMMARY OF THE DEMAND AFTER ISSUE OF ORDER BY THE APPELLATE AUTHORITY, REVISIONAL AUTHORITY, TRIBUNAL OR COURT

Reference no.

Date

1.	GSTIN/ Temporary ID/UIN -
2.	Name of the appellant / person -
3.	Address of the appellant / person -
4.	Order appealed against or intended to be revised-	Number-	Date-
5.	Appeal no.	Date-
6.	Personal Hearing -
7.	Order in brief-
8.	Status of order- Confirmed/Modified/Rejected
9.	Amount of demand after appeal / revision:

Particulars	Central tax		State/UT tax		Integrated tax		Cess		Total
Particulars	Amount in dispute / earlier order	Determined Amount	Amount in dispute / earlier order	Determined Amount	Amount in dispute / earlier order	Determined Amount	Amount in dispute / earlier order	Determined Amount	Amount in dispute / earlier order	Determined Amount
1	2	3	4	5	6	7	8	9	10	11
a) Tax
b) Interest
c) Penalty
d) Fees
e) Others
f) Refund

10. Place of supply wise details of IGST demand

Place of Supply (Name of State/UT)	Demand	Tax	Interest	Penalty	Other	Total
1	2	3	4	5	6	7
	Amount in dispute / earlier order
	Determined Amount

Place:
Date:
	Signature:
	Name of the Appellate Authority / Revisional
	Authority/ Tribunal / Jurisdictional Officer
	Designation:
	Jurisdiction: ".