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: