Application for refund of service tax

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....ments in support of the claim. 1. 2. 3. 4. 5. 3. The amount claimed was originally paid by TR-6 Treasury Challan No. _______ dated _______ deposited into _______ Treasury under the Head of Account ________ Service Tax on _______ miscellaneous receipts/by adjustment in account current No. _________ dated _________. OR The amount claimed was debited to account current No. ________ ....

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.... I/We declare that the goods received by me/us after payment of Central Excise duty for which refund has been claimed has been consumed by me/us as industrial consumer/has been sold in wholesale/retail. Dated Signature and full address of claimant Received payment Revenue Stamp (For amounts exceeding Rs. 20.00) _________________________________ Signature of claimant Claim of Shri/Messrs ____....