[See rule 100(3)]

Reference No.:                                                                                                                                 Date:


_______________ (GSTIN/ID)

_______________ Name

_______________ (Address)

Tax Period:                                                                                                                                                                 F.Y.:

Act/ Rules Provisions:

Preamble – << standard >>

It has come to my notice that un-accounted for goods are lying in stack at godown——– (address) or in a vehicle stationed at ———– (address & vehicle details) and you were not able to, account for these goods or produce any document showing the details of the goods. Therefore, I proceed to assess the tax due on such goods as under:


Discussion & finding:


Amount assessed and payable (details at Annexure):

(Amount in Rs,)

Please note that interest has been calculated up to the date of passing the order. While making payment, interest for the period between the date of order and the date of payment shall also be worked out and paid along with the dues stated in the order.

You are hereby directed to make the payment by << date >> failing which proceedings shall be initiated against you to recover the outstanding dues.


1 Substituted vide Notf No. 79/2020 CT dt 15.10.2020







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 (POS) details shall be required only if demand is created under IGST Act,]2


Download the Form here