FORM XII Application for refund of tax under section 14 of the Orissa Sales Tax Act, 1947 (See Rule - 39) To The Commissioner of Sales Tax. I......... Proprietor/ partner/ manager/ principal officer (authorised departmental) of the business known as ...... bearing Registration Certificate number ....... whose only / chief place of business in the district of ..... is situated at ...... P.O.......... pray for refund of Rs. ...... being the amount of excess [tax/ surcharge/ penalty/ security/ interest] paid by me. The refund may be paid in cash / by Refund Adjustment Order payable at the ........ Treasury / Sub-treasury. 1. Period of assessment in respect of which refund is claimed. order of assessment 2. Date on which ________________________________ was passed Final order on appeal, revision (...) or reference. 3. [(i) Amount of tax / surcharge / penalty paid.......] (ii) Challan Number ................. (iii) Date of payment............... 4. Amount as finally determined............ (Quote No. and date of order)............. 5. Amount of refund claimed. 6. Grounds for claiming refund. I ......... the applicant named above, do hereby declare that what is stated herein is true to the best of my knowledge and belief, (and also further declare that the amount of refund claimed above has been paid by me that the amount or any part thereof has not been realised by me by way of tax or otherwise from any person or persons. Signature
