THE GOA GOODS AND SERVICES TAX FORMS 2017
APPEAL AND REVISION

Form GST APL - 07

[See Rule 111(1) ]

Application to the Appellate Tribunal under sub section (3) of Section 112

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:

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	Integr ated 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 charges					< 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 Officer:

Designation:

Jurisdiction:-