THE ODISHA GOODS AND SERVICES TAX FORMS 2017
APPEAL AND REVISION

Body

Form GST APL - 01

[See Rule 108(1)]

Appeal to Appellate Authority

1.	GSTIN/ Temporary ID/UIN -
2.	Legal name of the appellant -
3.	Trade name, if any -
4.	Address -
5.	Order no. -	Order date -
6.	Designation and address of the officer passing the order appealed against -
7.	Date of communication of the order appealed against -
8.	Name of the authorized representative -
9.	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

(v) Market value of seized goods

10. Whether the appellant wishes to be heard in person - Yes / No

11. Statement of facts :-

12. Grounds of appeal:-

13. Prayer:-

14. Amount of demand created, admitted and disputed

Particulars of demand/ refund	Particulars		Central tax	State/ UT tax	Integrated tax	Cess	Total amount
	Amount of demand created (A)	a) Tax/ Cess					< total >	< total >
		b) Interest					< total >
		c) Penalty					< total >
		d) Fees					< total >
		e) Other charges					< total >
	Amount of demand admitted (B)	a) Tax/ Cess					< total >	< total >
		b) Interest					< total >
		c) Penalty					< total >
		d) Fees					< total >
		e) Other charges					< total >
	Amount of demand disputed (C)	a) Tax/ Cess					< total >	< total >
		b) Interest					< total >
		c) Penalty					< total >
		d) Fees					< total >
		e) Other charges					< total >

15. Details of payment of admitted amount and pre-deposit:-

(a) Details of payment required

Particulars		Central tax	State/ UT tax	Integrated tax	Cess	Total amount
(a) Admitted amount	Tax/ Cess						< total >
	Interest					< total >
	Penalty					< total >
	Fees					< total >
	Other charges					< total >
(b) Predeposit (10% of disputed tax /cess but not exceeding Rs. 25 crore each in respect of CGST, SGST or cess, or not exceeding Rs. 50 crore in respect of IGST and Rs. 25 crore in respect of cess)	Tax/ Cess					< total >
(c) Predeposit in case of subsection (3) of section 129	Penalty					< total >

(b) Details of payment of admitted amount and pre-deposit (pre-deposit 10% of the disputed tax and cess but not exceeding Rs. 25 crore each in respect of CGST, SGST or cess, or not exceeding Rs. 50 crore in respect of IGST and Rs. 25 crore in respect of cess)

Sr. No.	Description	Tax payable	Paid through Cash/ Credit Ledger	Debit entry no.	Amount of tax paid
Sr. No.	Description	Tax payable	Paid through Cash/ Credit Ledger	Debit entry no.	Central tax	State/UT tax	Integrated tax	CESS
1	2	3	4	5	6	7	8	9
1	Integrated tax		Cash Ledger
1	Integrated tax		Credit Ledger
2	Central tax		Cash Ledger
2	Central tax		Credit Ledger
3	State/UT tax		Cash Ledger
3	State/UT tax		Credit Ledger
4	CESS		Cash Ledger
4	CESS		Credit Ledger

Sr. No	Description	Amount payable				Debit entry no.	Amount paid
Sr. No	Description	Integrated tax	Central tax	State/UT tax	CESS	Debit entry no.	Integrated tax	Central tax	State/UT tax	CESS
1	2	3	4	5	6	7 .	8	9	10	11";
1	Interest
2	Penalty
3	Late fee
4	Others (specify)

16. Whether appeal is being filed after the prescribed period - Yes / No

17. If'Yes' in item 17-

(a) Period of delay -

(b) Reasons for delay -

18. Place of supply wise details of the integrated tax paid (admitted amount only) mentioned in the Table in sub-clause (a) of clause 15(item (a)), if any

Place of Supply (Name of State/UT)	Demand	Tax	Interest	Penalty	Other	Total
1	2	3	4	5	6	7
	Admitted amount [in the Table in subclause (a) of clause 15 (item (a))]

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:

Name of the Applicant: