"FORM ST ­ 5
                                                [See rule 9 (1)]

Form of Appeal to Appellate Tribunal under sub-section (1) of section 86 of the
                              Finance Act, 1994

        In the Customs, Central Excise and Service Tax Appellate Tribunal

            Appeal No.____________________________________ of 20...


.............................................................................................. Appellant

                                                    Versus

............... ........................................................................... Respondent


1. Assessee Code*                       Premises Code**                          PAN or UID***




 E-Mail Address                          Phone No.                               Fax No.




2. The designation and address of the authority passing the order appealed against.

3. Number and date of the order appealed against

               -                        -                -               -               -           -

Dated

                   -                        -

4. Date of Communication of a copy of the order appealed against.

5. State or Union territory and the Commissionerate in which the order or decision
of assessment, penalty was made.

6. If the order appealed against relates to more than one Commissionerate, mention
the names of all the Commissionerates, so far as it relates to the appellant.

7. Designation and address of the adjudicating authority in case where the order
appealed against is an order of the Commissioner (Appeals).

8. Address to which notices may be sent to the appellant.
9. Address to which notices may be sent to the respondent.

10. Whether the decision or order appealed against involves any question having a
relation to the rate of service tax or to the value of taxable service for the purpose of
assessment.






11. Description of service and whether in `negative list'.

12. Period of dispute.

13. (i) Amount of service tax, if any, demanded for the period of dispute .
    (ii) Amount of interest involved upto the date of the order appealed against.
    (iii) Amount of refund, if any, rejected or disallowed for the period of dispute.
    (iv) Amount of penalty imposed.

14. (i) Amount of service tax or penalty or interest deposited. If so, mention the
amount deposited under each head in the box below. (A copy of the challan under
which the deposit is made should be furnished)

  Service Tax              Penalty                   Interest


   (ii) If not, whether any application for dispensing with such deposit has been
   made?

15. Does the order appealed against also involve any central excise duty demand, and
related fine or penalty, so far as the appellant is concerned?

16. Does the order appealed against also involve any customs duty demand, and
related penalty, so far as the appellant is concerned?

17. Subject matter of dispute in order of priority. (please choose two items from the
list below)
[ i) Taxability - Sl. No. of Negative List, ii) Classification of Services, iii)
Applicability of Exemption Notification-Notification No., iv) Export of services.,
v) Import of services., vi) Point of Taxation., vii) CENVAT., viii) Refund., ix)
Valuation., x) Others.]

   Priority 1                           Priority 2



18. Central Excise Assessee Code, if registered with Central Excise.
19. Give details of Importer Exporter Code (IEC), if registered with Director General
of Foreign Trade.




20. If the appeal is against an Order-in-Appeal of Commissioner (Appeals), the
number of Orders-in-Original covered by the said Order-in-Appeal.

21. Whether the respondent has also filed appeal against the order against which
this appeal is made?

22. If answer to serial number 21 above is `yes', furnish the details of appeal.

23. Whether the appellant wishes to be heard in person?

24. Reliefs claimed in appeal.








                                       Statement of facts


                                       Grounds of appeal



Signature of the authorised
representative, if any.                                            Signature of the appellant




                                            Verification

I................................................. the appellant, do hereby declare that what is
stated above is true to the best of my information and belief.



Verified today , the .........day of .........................20.................


Signature of the authorised
representative, if any.                                            Signature of the appellant
Notes.- (1) The grounds of appeal and the form of verification shall be signed by the
appellant in accordance with rule 3 of the Central Excise (Appeals) Rules, 2001.
(2) The appeal including the statement of facts and the grounds of appeal shall be
filed in quadruplicate accompanied by an equal number of copies of the order (one of
which at least shall be a certified copy) appealed against.
(3) The appeal shall be in English (or Hindi) and should set forth,
concisely and under distinct heads, the grounds of appeal without any
argument or narrative and such grounds should be numbered consecutively.
(4) The appeal shall be accompanied by such fee as prescribed under sub-section
(6) of section 86 of the Act and shall be paid through a crossed bank draft drawn in
favour of the Assistant Registrar of the Bench of the Tribunal on a branch of any
nationalized bank located at the place where the Bench is situated.

                                      -----------


*15 digit Permanent Account Number (PAN) - based registration number to be
mandatorily furnished by registered persons.
**10 digit Commissionerate/ Division/ Range code (Premises Code) to be
mandatorily furnished by registered persons. This `premises code' is available in the
ST-2 Registration Certificate itself. In case of Centralized registrations the `premises
code' of the Main Office for which Centralized registration has been taken, should be
indicated.
*** To be furnished by non-registered persons. Unique Identification (UID) number to
be furnished where PAN is not available.