FORM A-1
[Refer condition at S. No. 3 (II)(a)]
Declaration by the SEZ Unit or Developer for availing ab initio exemption under
notification No.12/2013- Service Tax dated 1st July, 2013
1. Name of the SEZ Unit/Developer:
2. Addresses with telephone and Email:
3. Permanent Account Number (PAN) of the SEZ Unit/Developer:
4. Import and Export Code Number:
5. Jurisdictional Central Excise/Service Tax Division:
6. Service Tax registration number / Service Tax code / Central Excise
registration number:
7. Declaration: I/We hereby declare that-
(i)The information given in this application form is true, correct and complete in
every respect and I am authorised to sign on behalf of the SEZ Unit/Developer;
(ii)I/We maintain proper account of specified services, as approved by the
Approval Committee of SEZ, received and used for authorised operations in
SEZ; I/we shall make available such accounts and related records, at all
reasonable times, to the jurisdictional Central Excise officers for inspection or
scrutiny.
(iii)I/We shall use/have used specified services for authorised operations in the
SEZ.
(iv)I/We declare that we do not own or carry on any business other than the
operations in SEZ [where this item is not applicable, declaration may be submitted after
striking out the inapplicable portion];
OR
I/We declare that we also own/ carry on any business in domestic tariff area
as per the details furnished below:
Table I
S. Name of the unit Output services Goods manufactured
No. owned in DTA provided by DTA Unit by the DTA unit
(v)I/We are aware that the declaration is valid only for the purpose specified in
notification 12/2013-Service Tax dated 1st July, 2013 and is subject to fulfillment
of conditions.
(vi) I/We intend to claim ab initio exemption on the specified services mentioned
in the following Table:
Table II
Sl.No. Specified service(s) to be Details of service provider(s) who
received for the provide(s) the specified service(s), for SEZ
authorised operation authorised operations
Name and address Service Tax
registration
No./("self" in case
of service on which
service tax is paid
on reverse charge)
(1) (2) (3) (4)
(vii) I/We undertake that in case the services on which exemption has been claimed
were not exclusively used for authorised operation or were found not to have
been used exclusively for authorised operation, we shall pay to the government
an amount that is claimed by way of exemption from service tax along with
interest as applicable on delayed payment of service tax under the provisions of
the said Act read with the rules made thereunder.
Signature and name of authorised person with stamp
Date:
Place:
I have verified the above declaration; it is correct
Signature, date and stamp of the Specified Officer of the SEZ Unit /Developer
(Specified Officer shall retain a copy of the verified declaration, for the purpose of
record)
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