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FORM GST APL - 03

[See rule 109(1)]

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

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-

7. Statement of facts-

8. Grounds of appeal-

9. Prayer-

10. Amount of demand in dispute, if any -

Particulars of demand/refund, if any	Particulars		Central tax	State/UT tax	Integrated tax	Cess	Total amount
	(A) Amount of demand created, if any	a) Tax/ Cess
		b) Interest
		c) Penalty
		d) Fees
		e) Other charges
	(B) Amount under dispute	a) Tax/ Cess
		b) Interest
		c) Penalty
		d) Fees
		e) Other charges

Place ________________

Date _________________

Signature:

Name of the Applicant Officer:

Designation:

Jurisdiction: