Intimation to the applicant by the designated authority

[See section 6(2)] No.____________ To, ______________________ Partner/Proprietor/Manager/Director of ____________________ Address:_______________ _______________________ Registration No. _________________________ under the relevant Act. Arrears in respect of period of assessment 01-04- to 31-03-

Sir/Madam, With reference to your application No. _______ in Part A dated _________, for the settlement of arrears of tax, interest and penalty relating to the period ________________ received in my office on __________, you are hereby informed that the amount payable for settlement of arrears of tax and/or interest has been determined by me under sub-section (1) of section 6 of the Goa (Recovery of Arrears of Tax through Settlement) Act, 2009, as follows: (i) Arrears of tax in dispute (ii)Amount covered by furnishing Turnover Tax of declaration forms: C or D Forms E-I/E-II Forms F Form H Form Certificate in Form ST XIA Certificate in Form ST XI B Total........ (iii) Net arrears of tax [(i) - (ii)] Rs. .............. (iv) Arrears of interest Rs. .............. (v) Arrears of penalty Rs. ................ (vi) Amount of tax and interest determined payable for settlement: Tax Rs. Interest Rs. Total .............. (Rupees ______________________________ only)

Certified challan is enclosed. You are required to pay the amount by challan by _______________ and furnish receipted copy of the challan to this office. Date: Signature (Seal Designation (Appropriate designated authority)