ANNEXURE-IV
Government of ——-
Department of ——-
Form GST –
Refund Claim Form under —— Goods & Services Tax Act, —–
(To be used by Tax Payers only)
| 1. GSTIN |
| 2. Full Name of Taxpayer
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| 3. Taxpayer’s address
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Building Name/ Number
Area/ Road Locality/ Market Pin Code |
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| 4. Amount of refund claimed (Rs.) | IGST | CGST | SGST |
| 5. Ground for claiming refund
(provide reasons in detail, attach additional sheets, if required) [Attach /upload supporting documents) |
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| 6. Tax Period for which refund claimed | From | To | ||||||||||||||||
| d | d | mm | y | y | d | d | mm | yy | ||||||||||
- 8. Verification
I/We __________________________________________ hereby solemnly affirm and declare that the information given hereinabove is true and correct to the best of my/our knowledge and belief and nothing has been concealed therefrom.
Signature of Authorised Signatory ______________________________________
Full Name (first name, middle, surname) ______________________________________
Designation / Status ______________________________________
| Place |
| Date |
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| Day | Month | Year | ||||||||