FORM A-4

FORM A-4

[Refer condition at S. No. 3 (III)(c)]

Application for claiming refund of service tax paid on specified services used for authorised operations in SEZ under notification No.12/2013- Service Tax dated 1^st July, 2013

To

The Assistant/Deputy Commissioner of Central Excise/Service Tax

___________ Division, _______ Commissionerate Sir,

I /We having details as below,-

(i)  Name of the SEZ Unit/Developer:

(ii)  Address of the SEZ Unit/Developer with telephone and email:

(iii)  Address of the registered/Head Office with telephone and email:

(iv)  Permanent Account Number (PAN) of the SEZ Unit/Developer:

(v)    Import and Export Code Number:

(vi)  Jurisdictional Central Excise/Service Tax Division:

(vii) Service Tax Registration Number/Service      Tax   Code   /   Central   Excise

registration  number:

(viii)     Information regarding Bank Account (Bank, address of branch, account number) in which refund amount should be credited/to be deposited:

(ix)  Details regarding service tax refund claimed:

claim refund of Rs.................. (Rupees in words) as per the details furnished in the Table I and Table II below for the period from____________ to______________.

(A) Refund of service tax in respect of service tax paid on specified services exclusively used for the authorised operations in SEZ, as approved by the Approval Committee of the _________ SEZ [ Rupees____________] as per the details below

Table-I

S.

Description of

Name and

STC No. of

Invoice*

Date

Value of

Service

No.

taxable service

address of

service provider

No.

service

tax

service

(Indicate “ self” if

+cesses

provider

reverse charge

paid

applies to the

specified service)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

Total amount claimed as refund

*Certified copies of documents are enclosed.

(B) Refund on respect of service tax paid on specified services other than the services used exclusively for authorised operation (used partially for the authorised operations of SEZ Unit/Developer), as approved by the Approval Committee of the _________ SEZ [Rupees ____________].

Table-II

S.

Descriptio

Name

STC No.

Invoice*

Date

Value

Service

Amount

Document*

No.

n of

and

of service

No.

of

tax +

distributed

under which

taxable

address

provider

service

cess

to the SEZ

amount

service

of service

Amt

Unit/Devel

mentioned at

provider

-oper out

column (9) was

of the

distributed to

amount

the SEZ

mentioned

Unit/Developer

at column

No. (8)

(Claimed as

No.

Date

refund)

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(11)

Total Amount

*Certified copies of documents are enclosed

2.             (i) The turnover of the authorised operation of the SEZ Unit/Developer in the previous financial year:________________________;

(ii)  Turnover of the DTA operations in the previous financial year:____________

3.      I/We Declare that-

(i)       information given in this application for refund is true, correct and complete in every respect and that I am authorised to sign this application for refund of service tax;

(ii)   the specified services, as approved by the Approval Committee of SEZ, on which exemption/refund is claimed are actually used for the authorised operations in SEZ;

(iii)  we have paid the service tax amount along with the cesses, being claimed as refund vide this application, to the service provider;

(iv)   refund of service tax has not been claimed or received earlier, on the basis of above documents/information;

(v)   we have not taken any CENVAT credit under the CENVAT Credit Rules, 2004 of the

amount being claimed as refund;

(vi) proper account of receipt and use of the specified services on which exemption/refund is claimed, for the authorised operations in the SEZ, is maintained and the same shall be produced to the officer sanctioning refund, on demand.

Signature and name (of proprietor/managing partner/ person authorised by managing director of the SEZ Unit/Developer) with complete address, telephone and e-mail.

Date:                                                                      Place: