THE ODISHA GOODS AND SERVICES TAX FORMS 2017
APPEAL AND REVISION

Form GST APL - 03

[See Rule 109(1)]

Application to the Appellate Authority under sub-section (2) of Section 107

1.	Name and designation of the appellant		Name-
			Designation-
			Jurisdiction-
			State/Center-
			Name of the State-
2.	GSTIN/ Temporary ID /UIN-
3.	Order no.	Date-
4.	Designation and address of the officer 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 of demand in dispute, if any -

Particulars of demand/refund, 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 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 Applicant Officer:

Designation:

Jurisdiction: