Summary of Statement

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..... ) Grounds : (c) Tax and other dues : (Amount in Rs.) 2[Sr. No. Tax rate Turnover Tax Period Act POS (Place of Supply) Tax Interest Penalty Fee Others Total From To 1 2 3 4 5 6 7 8 9 10 11 12 13 Total ] Signature Name Designation Jurisdiction Address Note - 1. Only applicable fields may be filled up. 2. Column nos. 2, 3, 4 and 5 .....

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