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THE MADHYA PRADESH GOODS AND SERVICES TAX FORMS 2017
REFUND

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FORM-GST-RFD-01 A

[See rules 89(1) and 97A]

Application for Refund (Manual)

(Applicable for casual taxable person or non-resident taxable person, tax deductor, tax collector and other registered taxable person)

1 GSTIN / Temporary ID  
2 Legal Name  
3 Trade Name, if any  
4 Address  
5 Tax period (if applicable) From <Year><Month> To <Year><Month>
6

Amount of Refund Claimed(Rs.) Act Tax Interest Penalty Fees Others Total
Central tax            
State / UT tax            
Integrated tax            
Cess            
Total            
7

Grounds of Refund Claim (select from drop down) (a) Excess balance in Electronic Cash Ledger
(b) Exports of services- with payment of tax
(c) Exports of goods / services- without payment of tax (accumulated ITC)
(d) ITC accumulated due to inverted tax structure[under clause (ii) of first proviso to section 54(3)]
(e) On account of supplies made to SEZ unit/ SEZ developer(with payment of tax)
(f) On account of supplies made to SEZ unit/ SEZ developer (without payment of tax)
(g) Recipient of deemed export/ Supplier of deemed export

DECLARATION

[second proviso to section 54(3)]

I hereby declare that the goods exported are not subject to any export duty. I also declare that I have not availed any drawback of central excise duty/service tax/central tax on goods or services or both and that I have not claimed refund of the integrated tax paid on supplies in respect of which refund is claimed.

Signature

Name -

Designation / Status

DECLARATION [section 54(3)(ii)]

I hereby declare that the refund of ITC claimed in the application does not include ITC availed on goods or services used for making 'nil' rated or fully exempt supplies.

Signature

Name -

Designation / Status

DECLARATION [rule 89(2)(f)]

I hereby declare that the Special Economic Zone unit /the Special Economic Zone developer has not availed of the input tax credit of the tax paid by the applicant, covered under this refund claim.

Signature

Name -

Designation / Status

DECLARATION [rule 89(2)(g)]

(For recipients/supplier of deemed export)

In case of refund claimed by receipient

I hereby declare that the refund has been claimed only for those invoices which have been detailed in statement 5B for the tax period for which refund is being claimed and the amount does not exceed the amount of input tax credit availed in the valid return filed for the said tax period. I also declare that the supplier has not claimed refund with respect to the said supplies.

In case refund claimed by supplier

I hereby declare that the refund has been claimed only for those invoices which have been detailed in statement 5B for the tax period for which refund is being claimed. I also declare that the recipient shall not claim any refund with respect of the said supplies and also, the recipient has not availed any input tax credit on such supplies.

Signature  
Name -  
Designation / Status 

UNDERTAKING

I hereby undertake to pay back to the Government the amount of refund sanctioned along with interest in case it is found subsequently that the requirements of clause (c) of sub-section (2) of section 16 read with sub-section (2) of section 42 of the CGST/SGST Act have not been complied with in respect of the amount refunded.

Signature  
Name -  
Designation / Status 

SELF- DECLARATION [rule 89(2)(1)]

I/We (Applicant) having GSTIN/ temporary Id , solemnly affirm and certify that in

respect of the refund amounting to Rs. / with respect to the tax, interest, or any other amount for the period from---to, claimed in the refund application, the incidence of such tax and interest has not been passed on to any other person.

Signature

Name -

Designation / Status

(This Declaration is not required to be furnished by applicants, who are claiming refund under clause (a) or clause (b) or clause (c) or clause (d) or clause (f) of sub-section (8) of section 54.)

8. Verification

I/We<Taxpayer Name> hereby solemnly affirm and declare that the information given herein above is true and correct to the best of my/our knowledge and belief and nothing has been concealed therefrom.

I/We declare that no refund on this account has been received by me/us earlier.

Place Signature of Authorised Signatory
Date (Name)
  Designation/ Status

Annexure-1

Statement -1 [rule 89(5)]

Refund Type: ITC accumulated due to inverted tax structure [clause (ii) of first proviso to section 54(3)]

(Amount in Rs.)

Turnover of inverted rated supply of goods Tax payable on such inverted rated supply of goods Adjusted total turnover Net input tax credit Maximum refund amount to be claimed [(1x4/3)-2]
1 2 3 4 5
         
         

Statement 1A

[see rule 89(2)(h)]

Refund Type: ITC accumulated due to inverted tax structure [clause (ii) of first proviso to section 54(3)]

Sl. No.

Details of invoices of inward supplies received Tax paid on inward supplies Details of invoices of outward supplies issued Tax paid on outward supplies
GSTI N of the supplier No Date Taxable Value Integrated Tax Central Tax State Tax /Union territory Tax No Date Taxable Value Integrated Tax Central Tax State Tax /Union territory Tax
1 2 3 4 5 6 7 8 9 10 11 12 13

14

                           

Statement 2: [rule 89(2)(c)]

Refund Type: Exports of services with payment of tax

(Amount in Rs.)

Sr.No. Invoice details Integrated tax Cess BRC/FIRC Integrated tax and cess involved in debit note, if any Integrated tax and cess involved in credit note, if any Net Integrated tax and cess (6+7+10 - 11)
  No. Date Value Taxable value Amt.   No. Date      
1 2 3 4 5 6 7 8 9 10 11 12
                       

Statement- 3 [rule 89(2)(b) and 89(2)(c)]

Refund Type: Export without payment of tax (accumulated ITC)

(Amount in Rs.)

Sr.No.

Invoice details Goods/Services (G/S) Shipping bill/ Bill of export EGM Details BRC/ FIRC
No. Date Value   Port code No. Date Ref No. Date No. Date
1 2 3 4 5 6 7 8 9 10 11 12
                       

Statement- 3A [rule 89(4)]

Refund Type: Export without payment of tax (accumulated ITC) - calculation of refund amount

(Amount in Rs.)

Turnover of zero rated supply of goods and services Net input tax credit Adjusted total turnover Refund amount (1x2/3)
1 2 3 4
       
       

"Statement-4 [rule 89(2)(d) and 89(2)(e)]

Refund Type: On account of supplies made to SEZ unit or SEZ Developer (on payment of tax)

(Amount in Rs.)

GSTIN of recipient

Invoice details Shipping bill/ Bill of export/Endorsed invoice by SEZ Integrated Tax Cess Integrated tax and cess involved in debit note, if any Integrated tax and cess involved in credit note, if any Net Integrated tax and cess (8+9+1011)
No. Date Value No. Date Taxable value Amt.        
1 2 3 4 5 6 7 8 9 10 11 12
                       

Statement-5A [rule 89(4)]

Refund Type: On account of supplies made to SEZ unit / SEZ developer without payment of tax (accumulated ITC) - calculation of refund amount

(Amount in Rs.)

Turnover of zero rated supply of goods and services Net input tax credit Adjusted total turnover Refund amount (1x2/3)
1 2 3 4
       
       

"Statement 5B

[see rule 89(2)(g)]

Refund Type: On account of deemed exports

(Amount in Rs)

Sl. No.

Details of invoices of outward supplies in case refund is claimed by supplier/Details of invoices of inward supplies in case refund is claimed by recipient Tax paid
GSTIN of the supplier No. Date Taxable Value Integrated Tax Central Tax State Tax /Union Territory Tax Cess

1

2

3

4

5

6

7

8

9