SVLDRS-3 - Statement under section 127 of the Finance (No.2) Act, 2019 read with rule 6 of the Sabka Vishwas (Legacy Dispute Resolution) Scheme Rules, 2019 to be issued by the Designated Committee - SABKA VISHWAS (LEGACY DISPUTE RESOLUTION) SCHEME, 2019

1 [Form SVLDRS-3 [Statement under section 127 of the Finance (No.2) Act, 2019 read with rule 6 of the Sabka Vishwas (Legacy Dispute Resolution) Scheme Rules, 2019 to be issued by the Designated Committee] SABKA VISHWAS (LEGACY DISPUTE RESOLUTION) SCHEME, 2019 Declaration No . SVLDRS-3 No . Commissionerate/DGGI, Delhi Zone/DGGI, Delhi Whereas Mr./Ms./M/s. .............................................(hereinafter referred to as the declarant) having registration no./Non assessee code no. .has filed a Declaration No dated under section 125 of the Finance (No. 2) Act, 2019; Now, therefore, in exercise of the powers conferred by sub-sections (1) and (4), as the case may be, of section 127 of the Finance (No. 2) Act, 2019, the designated committee, after consideration of relevant material, hereby determines the following amount is payable by the declarant towards full and final settlement of tax dues under ..(Central Excise Act, 1944 /Finance Act, 1994/Cess Act) covered by the said declaration under the Scheme: Category Description of Goods/ Services Matter involved Time period Tax dues Tax relief Pre-deposit or any other deposit of duty Estimated Amount Payable A B C D E F G H Name* E1 Amount E2 Name* H1 Amt H2 *Name of Duty/Tax/Cess Notes: (1) The Declarant is hereby directed to make payment of the amount payable within thirty days from the date of this Statement. (2) The Declarant has to withdraw the writ petition/appeal/reference before .......................(mention the name of the High Court) High Court or the Supreme Court against any order in respect of the tax dues and furnish the proof of such withdrawal in accordance with the provisions contained in sub-section (7) of section 127 of the Finance (No. 2) Act, 2019; Members of the Designated Committee 2. Name: 2. Name: Designation: Designation: (This is a computer generated print. There is no need for a signature) Place . Date .. PREVIEW SUBMIT] ********* Notes: 1. Inserted vide Notification No. 05/2019 Central Excise-NT dated 21-08-2019 w.e.f. 01-09-2019