FORM A-3
[Refer condition at S. No. 3 (II)(d)]
Quarterly return to be furnished by the SEZ Unit/Developer furnishing the details of
services procured without payment of service tax in terms of the notification No.
12/2013-Service Tax dated 1st July, 2013
For the Quarter: April-June/Jul-Sep/Oct-Dec/Jan-March Year:
[Tick the appropriate quarter]
1. Name of the SEZ Unit/Developer:
2. Address of the SEZ Unit/Developer 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. We have procured the services as per the details below without payment of
service tax in terms of notification No. 12/2013-Service Tax dated 1st July, 2013
TABLE
S. Description of Name and Registration of Invoice Date Value of Service
No. taxable service address of service No. service tax + cess
service provider amount
provider claimed as
exemption
(1) (2) (3) (4) (5) (6) (7) (8)
Signature and name of authorised person with stamp
Date:
Place:
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