Form 4

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..... llip;……… Mr/ Mrs/ M/s .......................................................(Name and address of the declarant) (hereinafter referred to as declarant) had made a declaration under sub-section (1) of section 214 of the Finance Act, 2016 (28 of 2016) on …………..; and The designated authority by acknowledgement of even number in Form 2 dated ......... .....

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..... lip;……….; (b) granting immunity, from all from all proceedings under the Act, in respect of the indirect tax dispute for which the declaration has been made under this Scheme. Signature of the designated authority ……………… Place ……………… Name of the designated authority ……&hell .....

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