ANNEXURE-IV - Form GST – Refund Claim Form - To be used by Tax Payers only - Report on - Business Processes for GST on Refund Process - [August 2015]

ANNEXURE-IV Government of ------- Department of ------- Form GST Refund Claim Form under ------ Goods Services Tax Act, ----- (To be used by Tax Payers only) 1.GSTIN 2. Full Name of Taxpayer 3. Taxpayer s address Building Name/ Number Area/ Road Locality/ Market Pin Code 4. Amount of refund claimed (Rs.) IGST CGST SGST 5. Ground for claiming refund (provide reasons in detail, attach additional sheets, if required) [Attach /upload supporting documents) 6. Tax Period for which refund claimed From To dd mm yy dd mm yy 7. Details of Bank Account i) Bank Account No. ii) Bank Account Type iii) Operated in the name of iv) Name Address of Bank/Branch v) MICR No. / IFSC 8. Verification I/We __________________________________________ hereby solemnly affirm and declare that the information given hereinabove is true and correct to the best of my/our knowledge and belief and nothing has been concealed therefrom. Signature of Authorised Signatory ______________________________________ Full Name (first name, middle, surname) ______________________________________ Designation / Status ______________________________________ Place Date Date Month Year