Annexure-IV
GST CHALLAN FORM
| CPIN | <<Auto Generated after submission of information>> |
| GSTIN | <<Filled in/Auto populated>> |
|
Date | |
| Name | <<Auto Populated>> | Email address Mobile No. | <<Auto Populated>>
<<Auto Populated>> |
|
| Address | <<Auto Populated>> |
| Tax Liability | ||||||
| Tax | Interest | Penalty | Others | Total | ||
| Government of India | ||||||
| CGST | ||||||
| IGST | ||||||
| Additional Tax | ||||||
| Government of <State> | ||||||
| SGST | ||||||
| Tota | l Challan Amount | |||||
Note :
- Different colors to reduce possibility of data entry errors to be provided.
- Accounting Codes are to be provided for at the backend
Mode of Payment (relevant Portion to become active when selected)
| o e-Payment |
|
o Authorised Bank OTC | ||||
|
Net Banking o Credit Card o |
Name of
Receiving Bank ( where |
|||||
| Debit Card o |
|
instrument is proposed to be deposited) | ||||
| Name of Bank | Name of Branch (Optional) | |||||
| Name of
Payment Gateway (in case of payment through CC /DC) |
Name of
City/Town/Village where payment is proposed to be made |
|||||
| Details of instrument(optional) | ||||||
| Cash o
Cheque o DD o |
Ch/DD
No. |
|||||
| IFSC Code | ||||||
| Bank | ||||||
| Branch | ||||||
Note : Only local cheques ( not outstation cheques to be accepted)
| o NEFT/RTGS Remitting Bank |
|
||
| Name of Bank |
|
||
| Name of Branch | |||
| IFSC Code | |||
| Name and Code of Beneficiary Bank (RBI and its code) | |||
| Name of the
beneficiary account ( Description ‘GST payment’ to be auto Populated) |
|||
| Beneficiary Account
Number ( CPIN Auto Populated) |
|||
Note:
- Payments through RTGS / NEFT
- Beneficiary to be defined as the RBI and its account. This would be auto populated by GSTN
- Charges to be over and above Tax amount
Paid Challan Information
| Bank Reference No. |
|
Challan Received at | |
| CIN | |||
| Date of Clearing |
|
||
| NEFT/RTGS Unique Ref No. |