Summary of Statement

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..... . No. ---- Date Summary of Statement : (a) Brief facts of the case : (b) Grounds : (c) Tax and other dues : (Amount in Rs.) 2 [ Sr. No. Tax rate Turnover Tax Period Act POS (Place of Supply) .....

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..... ] Signature Name Designation Jurisdiction Address Note - 1. Only applicable fields may be filled up. 2. Column nos. 2, 3, 4 and 5 of the above Table i.e. tax rate, turnover and tax period are not mandatory. 3. Place of Supply .....

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..... Place of supply (name of State) Tax/ Cess Others Total 1 2 3 4 5 6 7 Total .....

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..... Total .....

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