Form No. SC(ST)-1 - Before the Customs and Central Excise Settlement Commission - Service Tax (Settlement of Cases) Rules, 2012

Form No. SC(ST)-1 [ See rule 3 of the Service Tax (Settlement of Cases) Rules, 2012] Before the Customs and Central Excise Settlement Commission ____________ Bench at __________ Form of application for settlement of a case under section 32E of Excise Act made applicable to service tax vide section 83 of the Finance Act, 1994 (32 of 1994) 1. Full name of the applicant: 2. (i) Postal address of the applicant (ii) E- mail address of the applicant, if any 3. (i) Address for communication: (ii) Telephone No. 4. (i) Permanent Account No: (ii) Service Tax registration No: (iii) Status: ( See note 2 ) 5. (i) Commissioner of Central Excise/Service Tax having jurisdiction over the applicant: (ii) Postal address of the Commissioner of Central Excise/Service Tax having jurisdiction over the applicant: 6. Details of Show Cause Notice issued to the applicant (a) Show Cause Notice No and date (b) Period of dispute in the notice (c) Service tax demanded in the notice (in Rs.) (d) Dispute in connection with which the application for settlement is made. (e) Adjudicating authority before whom the notice is pending adjudication. 7. (i) Whether service tax returns were filed for the period of dispute: (ii) Whether the invoices on taxable services are duly entered in the books of accounts. If so, details thereof. Note : Self-attested copies of relevant service tax returns and extracts from books of accounts/register to be enclosed. 8. Brief facts of the case and particulars of the issues to be settled and terms of settlement sought by the applicant: 9. (a) Amount of service tax accepted as payable for settlement (in Rs) (b) Interest on the said admitted service tax (in Rs.): (Detailed calculations of (a) and (b) above to be enclosed as Annexure-I) 10. Payment details of the service tax accepted, by the applicant, along with interest as at (9) above (TR-6 challan or G.A.R.-7 number and date) (Details to be enclosed as Annexure-II) 11. Whether any application for settlement (other than the present one) has been filed by the applicant before any Bench of Settlement Commission. If yes, the following information may be provided : (a) Application No. and date (b) Amount admitted for settlement (c) Show cause notice No. and date (d) Status of the application, if decided, then details of the final order of the Commission: (i) Settlement order No. and date (ii) Details of deposit of settlement amount (iii) Whether settlement amount has been paid in terms of the order (e) If any application of the applicant was sent back/rejected by the Settlement Commission, the reference number and date of the order (f) Reference number and date of the order, if any, in case the applicant was convicted of any offence under Chapter V of the Act in relation to a case settled earlier by the Settlement Commission 12. (i) Details of the order, if the applicant was ever debarred from making further application for settlement under section 32-O of Excise Act made applicable to Service Tax vide section 83 of the Act, by any of the Benches of the Settlement Commission (ii) Details of the order, if any settlement in respect of the applicant has ever been made void under section 32L of Excise Act made applicable to Service Tax vide section 83 of the Act, by any of the Benches of the Settlement Commission Signature of the applicant Verification I ..son/daughter/wife of . residing at . do solemnly declare that I am making this application in my capacity as .and I am competent to verify it. That the contents of this application are true and that I have not filed any application for settlement in contravention of the provisions of the Chapter V of Excise Act made applicable to service tax vide section 83 of the Act, before the Settlement Commission and also that no information relevant to the facts of the case has been suppressed. Annexures of the documents accompanying the application are true copies of the originals and the tables showing financial transaction are correct and are duly attested by me. That no proceeding in respect of the case for which settlement is being sought, is pending before Commissioner (Appeal), Customs, Excise and Service Tax Appellate Tribunal or the courts, as the case may be, or has been remanded back to the adjudicating authority by the said appellate authorities. Verified today the ..day of .(mention the month and year) at (mention the place) Deponent Note: 1. The application fee should be credited in a branch of the authorised bank or a branch of the State Bank of India or a branch of Reserve Bank of India and the triplicate copy of the challan sent to the Settlement Commission with the application. The Settlement Commission will not accept cheques, drafts, hundies or other negotiable instruments. 2. Please state whether individual, Hindu undivided family, company, firm, an association of persons, etc. 3. Details of the additional amount of Service Tax accepted as payable and interest thereon referred to in item 9 of the application shall be furnished in annexure to this application. 4. Original copy of the of the TR-6 challan indicating amount of service tax accepted as payable for settlement and interest thereon referred to in item 9 be retained by the applicant, duplicate be endorsed to the Central Excise Officer having jurisdiction over the applicant, triplicate be endorsed to the jurisdictional Chief Accounts Officer of the Central Excise or Service Tax Commissionerate as the case may be, quadruplicate be retained by the bank and quintuplicate copy be enclosed with this application form. In the case of G.A.R.-7, photocopies of tax payer's counterfoil, attested by the jurisdictional Central Excise Officer, may be furnished to various authorities. Annexure Statement containing particulars, referred to in item 8 of the application, made under section 32E (1) of Excise Act made applicable to service tax vide section 83 of the Act. 1. Details of information which has not been correctly declared in the periodical return; 2. Service tax liability accepted out of the total service tax demanded in the show cause notice issued and the manner in which such service tax liability has been derived; 3. Full and true disclosure of the facts regarding the issues to be settled including the terms of settlement sought for by the applicant.