[See rule 110(1)]

Appeal to the Appellate Tribunal

1.  GSTIN/ Temporary ID /UIN –

2.  Name of the appellant –

3.  Address of the appellant –

4.  Order appealed against-                                                   Number-                       Date-

5.  Name and Address of the Authority passing the order appealed against –

6.  Date of communication of the order appealed against –

7.  Name of the representative –

8.  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

9.  Whether the appellant wishes to be heard in person?

10. Statement of facts

11.  Grounds of appeal

12.  Prayer

13.  Details of demand created, disputed and admitted

14. Details of payment of admitted amount and pre-deposit:

(a) Details of amount payable:

(b) Details of payment of admitted amount and 2[(3[pre-deposit of 20% of the disputed tax and cess but not exceeding Rs. 50 crore each in respect of CGST, SGST or cess or not exceeding Rs.100 crore in respect of IGST and Rs. 50 crore in respect of cess]

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

4 [15. [Place of supply wise details of the integrated tax paid (admitted amount only)  mentioned in the Table in sub-clause (a) of clause 14 (item (a)), if any


I, < _________________________ >, 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.


Place:                                                                                                                                                                                                                         Date:


Name of the Applicant:

Designation /Status:


1. Substituted for “20% of disputed tax” vide Notification No. 03/2019-CT dated 29.01.2019 w.e.f. 01.02.2019. 2. Substituted vide Notification No. 03/2019-CT dated 29.01.2019 w.e.f. 01.02.2019. 3. Corrected by M.F. (D.R.) Corrigendum F. No. 20/06/16/2018-GST (Pt. 1), dated 05.02.2019. 4. Inserted (w.e.f. 01.02.2019) by Notification No. 03/2019-CT dated 29.01.2019.


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