Form 4

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..... ame and address of the declarant) (hereinafter referred to as declarant) had made a declaration under sub-section (1) of section 214 of the Finance Act, 2016 (28 of 2016) on ..; and The designated authority by acknowledgement of even number in Form 2 dated .............. acknowledged the said declaration; The Declarant has intimated as required under sub-section (3) of Section 214, the d .....

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..... Place Name of the designated authority Date Official Seal of the designated authority Copy To (1) The declarant (2) Assessing/Adjudicating Officer (3) Commissioner of Customs/ Central Excise/ Service Tax (4) Concerned appellant .....

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