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Form 1

Central Excise - [See rule 3(1)] FORM OF DECLARATION UNDER SUB SECTION (1) OF SECTION 214 OF THE FINANCE ACT, 2016 (28 OF 2016), IN RESPECT OF INDIRECT TAX DISPUTE RESOLUTION SCHEME, 2016 IN DUPLICATE To, The Designated Authority ............................................ ............................................ Sir/Madam, I hereby make a declaration under sub section (1) of section 214 of the Finance Act, 2016 (28 of 2016). 1 Name of the declarant (in block letters) 2 Registration Number .....

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................................ solemnly declare that to the best of my knowledge and belief, - (a) the information given in this declaration is correct and complete and amount due and other particulars shown therein are truly stated ; (b) I am not disqualified in any manner from making a declaration under the Scheme with reference to the provisions of section 215 of Finance Act, 2016. (c) I further declare that I am making this declaration in my capacity as ................... [(designation) ( .....

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