Appeal to the Joint commissioner of Income-tax (Appeals) or the Commissioner of Income-tax (Appeals)

1.

Name

(Refer Note 1)

2.

Address

(Refer Note 2)

3.

Permanent Account Number

4.

Tax deduction and collection account number

(Refer Note 3)

5.

Contact details (Refer Note 4)

Mobile Number

Country Code

Number

Email ID

Part B: Order against which Appeal is filed (Relevant order)

6.

Relevant Tax Year or Block Period

(i) Tax Year

(ii) Block period

(Select one)

(Refer Note 5)

7.

Details of Tax Year or Block Period as per reply to row 6

(Dropdown)

8.

Details of relevant order:

(i)

DIN of relevant order

(ii)

section and sub-section of the Act

(Dropdown)

(iii)

Date of relevant order

dd/mm/yyyy

(iv)

Date of service of notice of demand (where appeal relates to assessment or penalty)

dd/mm/yyyy

(v)

Date of service of relevant order (where appeal does not relate to assessment or penalty)

dd/mm/yyyy

(vi)

Income-tax

Authority

passing the

relevant order

Designation (For faceless write National Faceless Assessment Centre)

(Dropdown)

Assessing officer (AO code)

Area code

AO type

Range Code

AO no.

Part C: Details of Taxes paid

9.

Where an Income Tax Return has been filed by the appellant for the Tax year or Block Period for which the appeal is filed, whether tax due on income returned has been paid in full

(i) Yes

(ii) No

(iii) Not Applicable

(select one)

10.

If reply to row 9 is Yes, then enter details of such return and taxes paid:

(i)

Acknowledgement number of the return

(ii)

Date of filing of such return

dd/mm/yyyy

(iii)

Total income (₹)

(iv)

Total tax paid (₹)

11.

Where no Income Tax Return has been filed by the appellant for the Tax Year, whether an amount equal to the amount of advance tax as per section 358(6)(b) of the Act has been paid?

(i) Yes

(ii) No

(iii) Not Applicable

(select one)

12.

If reply to row 11 is Yes, then enter details of taxes paid:

BSR

Code

Date of payment

Sl. No.

Amount (₹)

Total

13.

If the appeal relates to any tax deductible under section 393(2) [Table: Sl. No. 17] of the Act and borne by the deductor, details of tax deposited:

BSR

Code

Date of payment

Sl. No.

Amount(₹)

Total

Part D: Appeal Details

14.

If order against which appeal is filed is passed under section 294 of Act, then provide the following details:

(i)

Amount of undisclosed income filed in Income Tax Return for Block assessment (₹)

(ii)

Amount of undisclosed income assessed (₹)

(iii)

Total addition of undisclosed income by the Assessing Officer (₹)[(ii)-(i)]

(iv)

Amount of disputed undisclosed income (₹)

(v)

Amount of disputed demand (₹)

15.

If appeal relates to assessment other than block assessment, then provide the following details:

(i)

Amount of Income Assessed (₹)

(ii)

Total addition to Income (₹)

(iii)

In case of Loss, total disallowance of Loss in assessment (₹)

(iv)

Amount of Addition/ Disallowance of Loss disputed in appeal (₹)

(v)

Amount of disputed demand (₹) – (Enter Nil in case of Loss)

16.

If appeal relates to penalty, then provide the following details:

(i)

Amount of penalty as per Order (₹)

(ii)

Amount of penalty disputed in appeal (₹)

17.

If appeal relates to TDS or TCS provisions, then provide the following details:

(i)

TDS or TCS Default Determined/Assessed (₹)

(ii)

TDS or TCS Default disputed in Appeal (₹)

Part E: Pending Appeal

18.

Whether any other appeal of same taxpayer is pending with any Joint Commissioner (Appeals) or Commissioner (Appeals)?

Tax

Year or

Block

Period

Order

under

section

Date of Order

Part F: Statement of facts, Grounds of Appeal and Additional evidence

19.

Statement ofFacts

(Upload)

20.

Grounds of Appeal (GoA)

Sl. No.

Grounds of Appeal

(Each Ground not

exceeding 100 words)

Relevant

section

mentioned in

GoA, if any

Amount

involved

(₹)

Whether any appeal on same ground

already decided (Yes/No)

(i)

(ifyes, then Upload) (Refer Note 6)

(ii)

(Repeat, if required)

21.

Whether any additional documentary evidence other than the evidence produced during the course of proceedings before the Income-tax Authority has been filed in terms of rule 192?

(i) Yes

(ii) No

(select one)

(Refer Note 7)

22.

If reply to row 21 is ‘Yes‘, furnish the following details:

(i)

Document Name

(ii)

The document attached is related to

which grounds of appeal (as given at row 20)

(iii)

Document

(Upload)

23.

Declaration in Form No. 117 (repetitive appeals) filed for the relevant tax year to which the appeal relates

(i) Yes

(ii) No

(select one)

24.

If ‘Yes to row 23, provide the following details:

(i)

Copy of Form No. 117 or the grounds stated therein

(Upload)

(ii)

Acknowledgement No. of Form No. 117

Part G: Appeal Filing Details

25.

Due date of filing appeal

dd/mm/yyyy

26.

Whether there is delay in filing appeal?

(i) Yes

(ii) No

(select one)

27.

If reply to row 26 is ‘Yes‘, provide the grounds for condonation of delay

(Upload)

28.

Details of Appeal Fees Paid:

BSR Code

Date of payment

Sl. No.

Amount (₹)

29.

Upload Supporting documents, if any.

SL

Description

Document

Relevant Grounds of Appeal

(i)

(Upload)

(ii)

(Upload)

(Repeat if required)

Form of verification

I, Permanent Account Number , do hereby declare that what is stated above is true to the best of my knowledge and belief.

It is also certified that I have not filed an application for immunity under section 440 of Act and no additional evidence other than the evidence stated in row 22 above has been filed. I further declare that I am making the declaration in my capacity as … … … … … … . and that I am competent to make this declaration and verify it.

Place

Date

(Signature)