FORM ST-4

Form of Appeal to the Commissioner of Central Excise (Appeals) under section 85 of the Finance Act,1994 (32 of 1994)

1. No.__________of______20___ :
2. Name and address of the appellant :
3. Designation and address of the officer passing the decision or order appealed against and the date of decision or order  :
4. Date of communication of the decision or order appealed against to the appellant :
5. Address to which notices may be sent to appellant :
5A. (i) Period of dispute :
(ii) Amount of service tax, if any, demanded for the period mentioned in column (i) :
(iii) Amount of refund, if any, claimed for the period mentioned in column (i)  :
(iv) Amount of interest :
(v) Amount of penalty :
(vi) Value of the taxable service for the period mentioned in column (i) :
6. Whether service tax or penalty or interest or all the three have been deposited? :
6A. Whether the appellant wishes to be heard in person? :
7. Relief claimed in appeal :

STATEMENT OF FACTS
Grounds of appeal

Signature of the authorised 
representative, if any

Signature of the
appellant

  Verification

I,______________________ the appellant, do hereby declare that what is stated above is true to the best of my information and belief.

Verified today, the ____________________ day of ___________

Place:
Date :

Signature of the authorised
representative, if any		 Signature of the appellant
or his authorised representative

Note :- The form of appeal including the statement of facts and the grounds of appeal shall be filed in duplicate and shall be accompanied by a copy of the decision or order appealed against.