FORM 5A

[See rule 9(2)]

Application under sub-section (2) of section 14 of the Madhya Pradesh Vat Act, 2002

To,

The ...................... (designation),

..................................Circle

I, .....................................................(name of the person) S/o..................................... do hereby declare that I have purchased goods specified in Schedule II (other than those specified in part III and part-III A of the Schedule) after payment to the selling registered dealer tax under section 9 of the Madhya Pradesh Vat Act, 2002 and being an *official / personnel / consular / diplomatic agent of............................. (specify name of foreign diplomatic mission / consulate / the United nations / any other similar international body), I am eligible to claim input tax rebate in respect of the goods purchased under sub-section (2) of section 14 of the said Act, therefore it is requested that the input tax rebate of the amount of tax paid to the selling registered dealer be allowed and granted by way of refund.

I,..................................................declare that to the best of my knowledge and belief the information furnished above is correct, complete and is truly stated.

*Strike out whichever is not applicable.

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ACKNOWLEDGMENT

Received an application in form 5 A from Shri ...........................................................for grant of refund of input tax rebate under rule 9 (2) of the Madhya Pradesh Vat Rules, 2006.

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