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Refund Claim Form (ANNEXURE – IV)

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

 

                         
                         

 

3. Taxpayer’s address

 

Building Name/ Number

Area/ Road

Locality/ Market

Pin Code

                           
                           
                           
             

 

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)

 
 
 
 

 

6. Tax Period for which refund claimed From                 To                
d d mm y y d d mm yy

 

 

 

  1. 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      

 

     

 

       
  Day Month Year

 

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