FORM NO. 4 - Form of Appeal to the Appellate Tribunal - Equalisation levy Rules, 2016

1 [ FORM NO. 4 [see rule 9 of Equalisation levy Rules, 2016] Form of Appeal to the Appellate Tribunal EL-4 In the Income-tax Appellate Tribunal . * Appeal No . of . APPELLANT Versus RESPONDENT 1. Permanent Account Number/ AADHAAR of the Appellant 2. The State in which the order was made 3. Section of Chapter VIII of the Finance Act, 2016 under which the order appealed against was passed 4. The Commissioner (Appeals) passing the order appealed against 5. Financial year in connection with which the appeal is preferred 6. Total amount of consideration for the financial year referred to in item 5 (as applicable): (a) for specified services paid/ credited (b) in respect of supply or services 7. Total amount of penalty levied by the Assessing Officer for the financial year referred to in item 5 8. The Assessing Officer passing the original order 9. Section of Chapter VIII of the Finance Act, 2016 under which the Assessing Officer passed the order 10. Date of communication of the order appealed against 11. Address to which notices may be sent to the appellant 12. Address to which notices may be sent to the respondent 13. Relief claimed in appeal 14. Amount in dispute: (a) Equalisation levy (b) Interest (c) penalty GROUNDS OF APPEAL 1. 2. 3. 4. etc. . . Signed Signed (Authorised representative, if any) (Appellant) Verification I, ., the appellant, do hereby declare that what is stated above is true to the best of my information and belief. Verified today the . day of . Place Signed Notes: 1. The memorandum of appeal shall be in triplicate accompanied by two copies (at least one of which should be a certified copy) of the order appealed against, two copies of the relevant order of the Assessing Officer, two copies of the grounds of appeal before the first appellate authority, two copies of the statement of facts, if any, filed before the said appellate authority. 2. The memorandum of appeal under sub-section (1) of section 175 of Chapter VIII of Finance Act, 2016 shall be accompanied by a fee of one thousand rupees. 3. The fee shall be credited in a branch of the authorised Bank or a branch of the State Bank of India or a branch of the Reserve Bank of India after obtaining a challan and the triplicate challan shall be sent to the Appellate Tribunal with a memorandum of appeal. The Appellate Tribunal shall not accept cheques, drafts, hundies or other negotiable instrument. 4. The memorandum of appeal shall be written in English or, if the appeal is filed in a Bench located in any such State as is for the time being notified by the President of the Appellate Tribunal for the purposes of rule 5A of the Income -tax (Appellate Tribunal) Rules, 1963, then, at the option of the appellant, in Hindi, and shall set forth, concisely and under distinct heads, the grounds of appeal without any argument or narrative and such grounds shall be numbered consecutively 5. *The number and year of appeal will be filled in the office of the Appellate Tribunal. 6. Delete the inapplicable columns. 7. If the space provided is found insufficient, separate enclosures may be used for the purpose. * NOTES 1. Please note that quoting false PAN/ AADHAAR may attract a penalty of Rs. 10,000/- as per section 272B of the Income-tax Act, 1961. 2. Taxpayers may please draw/ issue Cheque/ DDS towards payment of income-tax as under: Pay ______________ (Name of the Bank where the Challan is being deposited) A/c Income-tax KINDLY ENSURE THAT THE BANKS ACKNOWLEDGEMENT CONTAINS THE FOLLOWING:- 1. 7 DIGIT BSR CODE OF THE BANK BRANCH 2. DATE OF DEPOSIT OF CHALLAN (DD MM YYYY) 3. CHALLAN SERIAL NUMBER THESE WILL HAVE TO BE QUOTED THE STATEMENT OF SPECIFIED SERVICES OR E-COMMERCE SUPPLY OR SERVICES. ] *************** NOTES:- 1. Substituted vide Notification No. 87/2020 dated 28-10-2020 before it was read as, FORM NO. 4 [See rule 9 of Equalisation levy Rules, 2016] Form of appeal to the Appellate Tribunal EL-4 In the Income-tax Appellate Tribunal *Appeal No. of .. APPELLANT Versus .. RESPONDENT 1. The State in which the order was made : 2. Section of Chapter VIII of the Finance Act, 2016 under which the order appealed against was passed : 3. The Commissioner (Appeals) passing the order appealed against : 4. Financial year in connection with which the appeal is preferred : 5. Total amount of consideration for specified services paid/credited by the assessee for the financial year referred to in item 4 : 6. Total amount of penalty levied by the Assessing Officer for the financial year referred to in item 4 : 7. The Assessing Officer passing the original order : 8. Section of Chapter VIII of the Finance Act, 2016 under which the Assessing Officer assed the order : 9. Date of communication of the order appealed against : 10. Address which notices may be sent to the appellant : 11. Address to which notices may be sent to the respondent 12. Relief claimed in appeal GROUNDS OF APPEAL 1. 2. 3. 4. etc. Signed (Authorised representative, if any) Signed (Appellant) Verification I, , the appellant, do hereby declare that what is stated above is true to the best of my information and belief. Verified today the .. day of . Place . . Signed Notes: 1. The memorandum of appeal shall be in triplicate accompanied by two copies (at least one of which should be a certified Copy) or the order appealed against, two copies of the relevant order of the Assessing Officer, two copies of the grounds of appeal before the first appellate authority, two copies of the Statement of facts, if any, filed before the said appellate authority, 2. The memorandum of appeal by an assessee under sub-section (1) of section 175 of Chapter VIII of Finance Act, 2016 shall be accompanied by a fee of one thousand rupees. 3. The fee shall be credited in a branch of the authorised Bank or a branch of the State Bank of India or a branch of the Reserve Bank of India after obtaining a challan and the triplicate challan shall be sent to the Appellate Tribunal with a memorandum of appeal. The Appellate Tribunal shall not accept cheques, drafts, hundies or other negotiable instruments. 4. The memorandum of appeal shall be written in English or, if the appeal is filed in a Bench located in any such State as is for the time being notified by the President of the Appellate Tribunal for the purposes of rule 5A of the Income-tax (Appellate Tribunal) Rules, 1963, then, at the option of the appellant, in Hindi, and shall set forth, concisely and under distinct heads, the grounds of appeal without any argument or narrative and such grounds shall be numbered consecutively. 5.*The number and year of appeal will be filled in the Office of the Appellate Tribunal. 6. Delete the inapplicable columns. 7. If the space provided is found insufficient, separate enclosures may be used for the purpose. * NOTES 1. Please note that quoting false PAN may attract a penalty of Rs. 10,000/- as per section 272BB of Income-tax Act, 1961. 2. Tax payers may please draw/issue Cheque/DDs towards payment of income-tax as under: Pay ______________________ (Name of the Bank where the Challan is being deposited) A/c Income-tax 3. Deductor means a resident and carrying on business or profession or a non-resident having a permanent establishment in India, who is required to deduct the equalisation levy from the amount paid or payable to a non-resident in respect of specified service (section 166 of the Chapter VIII of the Finance, 2016). KINDLY ENSURE THAT THE BANK S ACKNOWLEDGEMENT CONTAINS THE FOLLOWING:- 1. DIGIT BSR CODE OF THE BANK BRANCH 2. DATE OF DEPOSIT OF CHALLAN (DD MM YY) 3. CHALLAN SERIAL NUMBER THESE WILL HAVE TO BE QUOTED IN YOUR STATEMENT OF SPECIFIED SERVICES. [Notification No. 38/2016: F. No. 370142/12/2016-TPL] (LAKSHMI NARAYANAN) UNDER SECRETRAY (TAX POLICY AND LEGISLATION)