THE GOA VALUE ADDED TAX RULES, 2005 FORMS
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Form VAT-XVI

[See rule 30(1) of the Goa Value Added Tax Rules, 2005]

Refund Adjustment order

Voucher No.

__________

Name of dealer of person to whom issued ___________________________________

TIN (In case of dealer registered under the Act)

Amount of refund due

Rs._____________________________

Date of order quantifying the refund amount. ________________________________

Details of amount deducted, if any on account of any demand outstanding against the applicant.

Amount	Demand Notice no.& date

(In words

6.	Net refundable amount in figures and works (3.5)	_________________________________
		(In figures
		Rs.__________________________
7.	The amount of Rs.................to be refunded by issue of Refund Voucher in Form VAT-XII.

Place:	Signature of Assessing Authority
Date:

(Seal of Assessing Authority)