ANNEXURE-IV - Form GST – Refund Claim Form - To be used by Tax Payers only - Report on - Business Processes for GST on Refund Process - [August 2015]

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

dd

mm

yy

dd

mm

yy

 

7. Details of Bank Account

i)     Bank Account No.

ii)    Bank Account Type

iii)   Operated in the name of

iv)    Name & Address of Bank/Branch

v)     MICR No. / IFSC

 

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	Date	Month	Year