[See rule 108(1)]

Appeal to Appellate Authority

1. GSTIN/ Temporary ID/UIN–

2. Legal name of the appellant

3. Trade name, if any –

4. Address –

5. Order no. –                                                                          Order date –

6. Designation and address of the officer passing the order appealed against –

7. Date of communication of the order appealed against –

8. Name of the authorised representative –

9. Details of the case under dispute –

(i) Brief issue of the case under dispute –

(ii) Description and classification of goods/ services in dispute-

(iii) Period of dispute

(iv) Amount under dispute:

(v) Market value of seized goods

10. Whether the appellant wishes to be heard in person –

Yes / No

11. Statement of facts:-

12. Grounds of appeal:-

13. Prayer:-

14. Amount of demand created, admitted and disputed

1[15. Details of payment of admitted amount and pre-deposit:-

(a) Details of payment required

(b) Details of payment of admitted amount and pre-deposit (pre-deposit 10% of the disputed tax and cess but not exceeding Rs 25 crore each in respect of CGST. SGST or cess, or not exceeding Rs 50 crore in respect of IGST and Rs 25 crore in respect of cess)

(c) Interest, penalty, late fee and any other amount payable and paid

16. Whether appeal is being filed after the prescribed period – Yes / No

17. If ‘Yes’ in item 17 –

(a) Period of delay –

(b) Reasons for delay –

3[18. [Place of supply wise details of the integrated tax paid (admitted amount only) mentioned in the Table in sub-clause (a) of clause 15 (item (a)), if any


1.  <_________________>, hereby solemnly affirm and declare that the information given hereinabove is true and correct to the best of my knowledge and belief and nothing has been concealed therefrom.


Date:                                                                                                                                                     <Signature>

                                                                                                   Name of the Applicant:


1. Substituted (w.e.f. 01.02.2019) vide Notification No. 03/2019-CT dt. 29.01.2019. 2. Substituted (w.e.f. 01.01.2022) vide Notification No. 40/2021-CT dated 29.12.2021. 3. Inserted (w.e.f. 01.02.2019) vide Notification No. 03/2019-CT dt. 29.01.2019


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