Application for filing a claim of rebate of duty paid on inputs, service tax and cess paid on input services

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..... mmissioner of Central Excise/Deputy Commissioner of Central Excise …………… ……………..(full postal address). Madam/Sir, I/We……………… …………………..,(name of the person claiming rebate) holding service tax registration No. ………&hel .....

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..... ……. (amount in rupees of cess) has been paid on input services and duty amounting to ………… (amount in rupees of duty) has been paid on inputs. 2. I/We also declare that the payment against such service exported has already been received in India in full……………………… ………… .....

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..... lip;………… . (Signature and name of the service provider or his authorised agent with date) (PART B: To be filled by the sanctioning authority) Date of receipt of the rebate claim: …………… Date of sanction of the rebate claim: …………… Amount of rebate claimed: ………… Rs. Amount .....

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