(Application for filing a claim of rebate of duty paid on inputs, service tax and cess paid on input services)
Assistant Commissioner of Central Excise/Deputy Commissioner of Central Excise ..(full postal address).
I/We ..,(name of the person claiming rebate) holding service tax registration No. , located in . (address of the registered premises) hereby declare that I/We have exported service (name of the taxable service) under rule 5 of the Export of Service Rules, 2005 to (name of the country to which service has been exported), and service tax amounting to . (amount in rupees of service tax) and education cess amounting to . (amount in rupees of cess) has been paid on input services and duty amounting to (amount in rupees of duty) has been paid on inputs.
2. I/We also declare that the payment against such service exported has already been received in India in full . (details of receipt of payment).
3. I/We request that the rebate of the duty, service tax and cess on inputs and input services used in providing taxable service exported by me/us in terms of rule 3 of the Export of Service Rules, 2005 may be granted at the earliest. The following documents are enclosed in support of this claim for rebate.
(a) We hereby certify that we have not availed CENVAT credit on inputs and input services on which rebate has been claimed.
(b) We have been granted permission by Assistant Commissioner of Central Excise or Deputy Commissioner of Central Excise, vide C. No. ______, dated ______ for working under notification No. _____ , dated _____ .
(Signature and name of the service provider or his authorised agent with date)
Date of receipt of the rebate claim: ______________
Date of sanction of the rebate claim: ______________
Amount of rebate claimed: Rs. ______________
Amount of rebate sanctioned: Rs. ______________
If the claim is not processed within 15 days of the receipt of the claim, indicated briefly reasons for delay.
Signature of the Assistant Commissioner/ Deputy Commissioner of Central Excise.