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The applicant on the above application has paid a net amount of Rs. ——————— ——— as final settlement, which has been accepted. ISSUED this ________ day of __________. Signature (Seal) Designation (Appropriate designated authority)] Secretariat, V. P. SHETYE, Porvorim-Goa. Secretary to the Government of Goa, Dated: 25-8-2009. Law Department (Legal Affairs Division). Annexure-A PART A Application for Settlement (See section 5) To, The Designated Authority, _____________________ _____________________ _____________________ I ______________________________________________ Proprietor/Partner/Karta/Managing Director / Director / Principal Officer / duly authorized officer / President / Secretary / legal heir / /Successor/assignee or nominee/myself/on behalf of an applicant, being eligible under section 4 of the Goa (Recovery of Arrears of Tax through Settlement) Act, 2009, hereby apply for settlement of arrears of tax, penalty and interest. I furnish hereunder the requisite particulars:— (1) Name of the applicant: (2) Status of the applicant: (3) Name and Style of the business: or The trade name of the business: (4) Address of the Business.— (i) Principal place of business: (ii) Add. place of business: (iii) Factory premises: (5) Present postal address, if it is different from (4) above: (6) Reference to Certificate of Registration: (i) VAT TIN (ii) CST No. (iii) Entry Tax Regn. No. (iv) Luxury Tax Regn. No. (v) Pre-VAT Sales Tax No. (7) Period in respect of assessment of tax, interest 01-04- to 31-03- and penalty, to which the application relates Whether it is (Enclose copy of the assessment Luxury Tax/ order for reference.) /Sales Tax/ /Entry Tax:- (8) Arrears of tax applied for Settlement: (i) Tax in arrears: (ii) Interest in arrears: (iii) Penalty in arrears: __________ Total __________ (9) (i) Whether the arrears is disputed in the appeal/ /revision/review. (ii) If yes, please give the reference of the appeal/petition filed (Please enclose a copy thereof). (iii) Authority with which it is pending either for hearing or decision. (iv) Date of presentation of appeal/review/revision, so pending. (10) Whether, any declaration in Form C or D, Form E-I/E-II or Form F or Form H or certificate in Form ST XI A or ST XI B is collected subsequent to assessment which C Form Rs. helps to reduce the arrears of tax. D Form Rs. If so, please file the said forms, E-I Form alongwith the statements. Rs. E-II Form Rs. F Form Rs. H. Form Rs. ST XI A Rs. ST XI B Rs. ................... ................... (11) Net amount of arrears applied for settlement Tax Rs. Interest Rs. Penalty Rs. _______ Total _______ VERIFICATION I/We .................................................. solemnly declare that to the best of my/our knowledge and belief,— (a) the particulars and information given in this application are correct and complete; (b) the amount of arrears of tax, interest and penalty shown hereinabove are truly stated and relate to the relevant period as mentioned in this application; and (c) I/ the applicant am/is not otherwise ineligible for making this application in terms of the provisions of said Act. ............................................. (Signature) ............................................................. (Name of the signatory in full) ........................................................................ (Status in relation to the applicant) Place: Date: PART B Intimation to the applicant by the designated authority [See section 6(2)] No.____________ To, ______________________ Partner/Proprietor/Manager/Director of ____________________ Address:_______________ _______________________ Registration No. _________________________ under the relevant Act. Arrears in respect of period of assessment 01-04- to 31-03- Sir/Madam, With reference to your application No. _______ in Part A dated _________, for the settlement of arrears of tax, interest and penalty relating to the period ________________ received in my office on __________, you are hereby informed that the amount payable for settlement of arrears of tax and/or interest has been determined by me under sub-section (1) of section 6 of the Goa (Recovery of Arrears of Tax through Settlement) Act, 2009, as follows: (i) Arrears of tax in dispute (ii)Amount covered by furnishing Turnover Tax of declaration forms: C or D Forms E-I/E-II Forms F Form H Form Certificate in Form ST XIA Certificate in Form ST XI B ......... .......... ........ Total........ .......... ........ (iii) Net arrears of tax [(i) - (ii)] Rs. .............. (iv) Arrears of interest Rs. .............. (v) Arrears of penalty Rs. ................ (vi) Amount of tax and interest determined payable for settlement: Tax Rs. Interest Rs. Total .............. (Rupees ______________________________ only) Certified challan is enclosed. You are required to pay the amount by challan by _______________ and furnish receipted copy of the challan to this office. Date: Signature (Seal Designation .............................................................................. (Appropriate designated authority) PART C Certificate of settlement issued by the designated authority [See section 8(1)] On the basis of the application made by ______________ (name of the applicant), who is carrying on/used to carry on the business in the trade, name of ____________________________ at __________________ (address) and who is/was holding R. C. (Local/Central/Luxury/Entry) No. ___________________ and TIN No. ____________________________________ under the _________________________ (name of the relevant Act), it is certified that:— *(1) Arrears of tax, interest or penalty arisen on account of the order of assessment for the period from _________ to ________ against which, no appeal is preferred upto _______ has been settled under sub-section (1) of section 8 of the Settlement of Appeals and Arrears under Goa Sales Tax, Central Sales Tax, Goa Tax on Luxuries and Goa Tax on Entry of Goods Act, 2009. *(2) Arrears of tax, interest and penalty arisen for the assessment period ________________ which was pending in review/appeal/revision before __________________ (name of the appropriate review/appellate/revisional authority), being review/appeal/revision case No. ________________, has been settled under sub-section (1) of section 8 of the Goa (Recovery of Arrears of Tax through Settlement) Act, 2009. The applicant on the above application has paid a net amount of Rs............................... as final settlement, which has been accepted. ISSUED this ________ day of __________. Signature Designation (Appropriate designated authority) (Seal) *Strike out whichever is not applicable. N.B.: Endorse one copy of the settlement certificate Part A, Part B, and Part C to the Commissioner