FORM RD IV

(See Rule 4(5))
Claim for Refund

1.Name of the dealer                                 :
 

2.If refund is sought in pursuance of an order
of assessment.                                                             :

(i) No. and date of order of assessment.             :

(ii) Date of notice of final assessment and
      refund order.                                                           :

(iii)Date on which the notice of final           
      assessment and refund order was
      served on the dealer.                                        :

(iv)Amount of refund order.                                    :

3.If refund is sought in pursuance of an order
passed in appeal or revision                                     :

(i)No. and date of order of the appellate
     or revisional authority.                 :

 (ii) Date of revised notice of final
     assessment and order of refund.              :

 (iii)Date on which the notice of final
      assessment and order of refund was
      served on the dealer.                                    :

(iv)    Amount of refund due.                        :

                                                                                                                                                        Signature of claimant

                    Signature of the authorised Representative if any

VERIFICATION

I/We _____________________________________________ the applicants do hereby declare that what is stated above is true to the best of my/our knowledge and belief.

 Verified today the _____________________ day of ___________________________ 20______

Signature of the applicant(s)

Signature of the Authorised Representative, if any.