FORM 1 - FORM OF DECLARATION UNDER SECTION 94 OF THE FINANCE ACT, 2008 IN RESPECT OF DISPUTE RESOLUTION SCHEME, 20 - Dispute Resolution Scheme Rules, 2008

FORM 1 [See sub-rule (1) of rule 3] FORM OF DECLARATION UNDER SECTION 94 OF THE FINANCE ACT, 2008 IN RESPECT OF DISPUTE RESOLUTION SCHEME, 2008 To The Designated Authority ………………. ………………. Sir/Madam, I hereby make a declaration under section 94 of the Finance Act, 2008. 1. Name of the declarant : …………………………… (in block letters) 2. Address : ………………………………………….. ………………………………………………………. ……………………..Telephone No…………………. 3. STC Code………………….. 4. Premises code 5. Details of the case and tax arrears proposed for settlement under the Scheme: TABLE (1) (2) (3) (4) (5) (6) Show cause / demand notice No. and date of issue** Nos. and date of order in original/order in appeals passed in the matter, if any** Amount of tax arrears involved (in Rs) (see Instruction 4) Service tax + Education cess (Primary) + Secondary and higher education cess Interest Penalty Amount claimed as payable for the case under section 94 (in Rs.) Details of writ petition/appeal reference filed before a high Court the Supreme Court, if any Remarks ** The Scheme does not apply to any order or notice issued under section 73A of the Finance Act, 1994 VERIFICATION I…………………. (name in block letters) son/daughter of Shri……………….solemnly declare that to the best of my knowledge and belief - (a) the information given in this declaration and statements and annexure accompanying it is correct and complete and amount of tax arrears and other particulars shown therein are truly stated; (b) I am not disqualified under provisions of section 93 of Finance Act, 2008 from making a declaration. I further declare that I am making this declaration in my capacity as ……………………..(designation) (Please specify if you are making a declaration on behalf of declaring) and that I am competent to make this declaration and verify it. NAME AND SIGNATURE OF DECLARANT PLACE: DATE: Instructions: 1. This Form should be submitted to the Central Excise Officer notified as designated authority under section 92(b) of the Finance Act, 2008. 2. Wherever the entry is not relevant, the column shall be filled in as "Not Applicable". 3. In column (2), the details of order passed in original adjudication or order passed in appeal by Commissioner (Appeals) or by Customs, Excise and Service Tax Appellate Tribunal or a High Court should be clearly indicated and relevant documentary evidence shall be enclosed. 4. In column (3), the tax arrears may be declared in terms of the meaning given to it in section 94 of the Finance Act, 2008 . 5. Any other information relevant to the case may be briefly indicated under column 5.