FORM 5-B

.(See rule 8 (4-A))

Return verification Form

Name and address of the Dealer

(Affix seal)

Acknowledgment Number

(1) Gross Turnover

(2) Turnover of tax free goods

(3)(a) Turnover of goods specified in part III of Schedule II

(b) (Specify, if any other deduction)

(4) Taxable turnover [(1-(2+3)]

(5) Turnover relating to sale of goods purchased included in serial number (4)

(6) Turnover relating to cooked food manufactured included in serial number (4)

(7) Turnover relating to other goods manufactured included in serial number (4)

(8) Lump-sum @ 0.5% on turnover mentioned in serial number (5)

(9) Lump-sum @ 3% on turnover mentioned in serial number (6)

(10) Lump-sum @ 4% on turnover mentioned in serial number (7)

(11) Total lump-sum payable (8+9+10)

(12) Amount payable under sub-section (3) of section 11

(13) Total amount payable (11+12)

(14) Total amount paid

Declaration

I ....................................(Name) being .................................... of the above business firm do hereby declare that the information and particulars given in the return which has been transmitted electronically by me vide acknowledgment number mentioned above are true and correct to the best of my knowledge and belief.

Note: This Form shall be signed by any person as prescribed in sub-rule (1) of rule 11 of the Madhya Pradesh Vat Rules. 2006.

For Office Use only

Return Verification Form for the Quarter/ year / month of F.Y. .....................

Return Verification Form Receipt Number: .................. Date .../../..