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)