FORM GST APL – 03

[See rule 109(1)]

Application to the Appellate Authority under sub-section (2) of Section 107

1. Name and designation of the appellant

Name-

Designation-

Jurisdiction-

State/Center-

Name of the State

2. GSTIN/ Temporary ID /UIN

3. Order no Date-

4. Designation and address of the officer passing the order appealed against

5. Date of communication of the order appealed against

6. 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-

DescriptionCentral taxState/ UT
tax		Intgrated
tax		Cess
a) Tax/ Cess
b) Interest
c) Penalty
d) Fees
e) Other charges

7. Statement of facts –

8. Grounds of appeal –

9. Prayer –

10. Amount of demand in dispute, if any –

Place:

Date:

Signature>

Name of the Applicant Officer:

Designation:

Jurisdiction:

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