FORM

(See rule 3)

Application for Compounding of Offence

1. Full Name and permanent address of the applicant:

2. Address for communication:

3. (i) Permanent Account Number (PAN):

(ii) Service Tax Registration No:

4. Commissioner of Central Excise/Service Tax having jurisdiction over the applicant:

5. Specific provision(s) of Chapter V of the Finance Act, 1994, against whose violation, prosecution is instituted or contemplated for which application of compounding is being filed:

6. Details of Adjudication Order in relation to the case for compounding:

7. Brief facts of the case and particulars of the offence (s) charged:

8. Whether Show Cause Notice issued:

9. If yes, details of service tax demanded:

10. Whether Show Cause Notice has been adjudicated:

11. If yes, adjudication details:

(a) Amount of service tax confirmed:

(b) Amount of CENVAT credit to be recovered/denied:

(c) Penalty imposed:

12. Whether this is the first offence under Chapter V of the Finance Act, 1994, if not, details of previous cases:

13. Whether any proceedings for the same offence contemplated under any other law, if so, the details thereof:

Name and Signature of the applicant.

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DECLARATION

1. I shall pay the compounding amount, as may be fixed by the compounding authority under sub-rule (3) of rule 4 of the Service Tax (Compounding of Offences) Rules, 2012.

2. I understand that I shall not claim, as of right that the offence committed by me under the Act be compounded.

Name and Signature of the applicant.

VERIFICATION

I, _______ son/daughter/wife of ____________ residing at __________do solemnly declare that I am making this application in my capacity as ______ and I am competent to verify it.

That the contents of this application are true to the best of my knowledge and belief and no information relevant to the facts of the case has been suppressed. The documents accompanying the application are true copies of the originals and the tables showing financial transactions are correct and are duly attested by me.

Verified today the _____________ day of (month) __________ (year) at_________.

Name and Signature of the applicant.

Place:

Date: