Appeal to the Appellate Tribunal in Form GST APL-05, with statement of facts, grounds and prayer

Bench before which filed

[State Bench at ____ / Principal Bench, New Delhi — the place of supply being in issue, section 109(5)]

GSTIN and legal name of the appellant

[____]

Order appealed against

Order-in-Appeal No. [____] dated [DD.MM.YYYY] passed by the [Joint / Additional] Commissioner (Appeals) of [Central / State] Tax, [____]

Order-in-Original to which it relates

No. [____] dated [DD.MM.YYYY], with Form GST DRC-07 Reference No. [____]

Date of communication of the Order-in-Appeal

[DD.MM.YYYY]

Whether against the whole or a part

[Whole / Part — paragraphs __, __ and __ only]

Tax period

[April ____ to March ____]

Category of the case

[Category I — input tax credit / classification / demand under section 73]

Whether place of supply is in issue

[Yes / No]

Appeal fee paid

Rs [____] — being Rs 1,000 per Rs 1,00,000 of the amount in dispute of Rs [____], subject to the minimum of Rs 5,000 and the maximum of Rs 25,000. Challan / payment reference [____] dated [DD.MM.YYYY]