FORM JVAT 122

GOVERNMENT OF JHARKHAND

COMMERCIAL TAXES DEPARTMENT

Indemnity Bond for loss of Declaration Form in JVAT 505 series

[See Rule 35(8), 36(5), 42(9)]

I, Sri______________________________ son/daughter/wife of Sri _____________________ residing at _______________________________ P.O. ____________ P.S. _____________________ Dist ____________, Proprietor/Partner/(Managing) Director/Manager/Principal Officer/Authorised officer of the Dealer / Business known as _________________________________ situated at _______________________________________ and possessing a Tax-payers' Identification number bearing TIN_________________ in the State of Jharkhand under the Jharkhand Value Added Tax Act, 2005, do hereby declare that the Declaration form bearing no. ________________ issued online from official website by me on .................................. has to be cancelled for the following reasons

(i) Errors or omission in entry of particulars

(ii) Others (Please specify) …………………………………………………………………

(Strike out whichever is not applicable)

And I, the aforesaid Sri ________________________________ do hereby undertake to hold harmless and to indemnify the Government against any loss arising out of the aforesaid loss of Declaration Form.

And I bind myself, my heirs, executors, administrations and assignees and each one of the other person having any share, title or interest in the aforesaid business and his heirs, executors, administrators and assignee jointly and severally for holding harmless and indemnifying the Government for any such loss and aforesaid.

Place :

Date :

Signature of the dealer

Designation with relation to the business :