FORM A-4
[Refer condition at S. No. 3 (III)(c)]
Application for claiming refund of service tax paid on specified services used for
authorised operations in SEZ under notification No.12/2013- Service Tax dated 1st
July, 2013

To
The Assistant/Deputy Commissioner of Central Excise/Service Tax
___________ Division, _______ Commissionerate
Sir,
I /We having details as below,-
(i) Name of the SEZ Unit/Developer:
(ii) Address of the SEZ Unit/Developer with telephone and email:
(iii) Address of the registered/Head Office with telephone and email:
(iv) Permanent Account Number (PAN) of the SEZ Unit/Developer:
(v) Import and Export Code Number:
(vi) Jurisdictional Central Excise/Service Tax Division:
(vii) Service Tax Registration Number/Service Tax Code / Central Excise
registration number:
(viii) Information regarding Bank Account (Bank, address of branch, account
number) in which refund amount should be credited/to be deposited:
(ix) Details regarding service tax refund claimed:
claim refund of Rs.................. (Rupees in words) as per the details furnished in the Table I
and Table II below for the period from____________ to______________.
(A) Refund of service tax in respect of service tax paid on specified services exclusively
used for the authorised operations in SEZ, as approved by the Approval Committee of
the _________ SEZ [ Rupees____________] as per the details below
Table-I
S.
No.
Description of
taxable service
Name and
address of
service
provider
STC No. of
service provider
(Indicate “ self” if
reverse charge
applies to the
specified service)
Invoice*
No.
Date Value of
service
Service
tax
+cesses
paid

(1) (2) (3) (4) (5) (6) (7) (8)
Total amount claimed as refund
*Certified copies of documents are enclosed.
(B) Refund on respect of service tax paid on specified services other than the services
used exclusively for authorised operation (used partially for the authorised operations
of SEZ Unit/Developer), as approved by the Approval Committee of the _________ SEZ
[Rupees ____________].Table-II
S.
No.
Descriptio
n of
taxable
service
Name
and
address
of service
provider
STC No.
of service
provider
Invoice*
No.
Date Value
of
service
Service
tax +
cess
Amt
Amount
distributed
to the SEZ
Unit/Devel
-oper out
of the
amount
mentioned
at column
No. (8)
Document*
under which
amount
mentioned at
column (9) was
distributed to
the SEZ
Unit/Developer
(Claimed as
refund)
No. Date
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11)
Total Amount
*Certified copies of documents are enclosed
2. (i) The turnover of the authorised operation of the SEZ Unit/Developer in the
previous financial year:________________________;
(ii) Turnover of the DTA operations in the previous financial year:____________
3. I/We Declare that-

(i) information given in this application for refund is true, correct and complete in
every respect and that I am authorised to sign this application for refund of service tax;
(ii) the specified services, as approved by the Approval Committee of SEZ, on which
exemption/refund is claimed are actually used for the authorised operations in SEZ;
(iii) we have paid the service tax amount along with the cesses, being claimed as refund
vide this application, to the service provider;
(iv) refund of service tax has not been claimed or received earlier, on the basis of above
documents/information;
(v) we have not taken any CENVAT credit under the CENVAT Credit Rules, 2004 of the
amount being claimed as refund;
(vi) proper account of receipt and use of the specified services on which
exemption/refund is claimed, for the authorised operations in the SEZ, is maintained
and the same shall be produced to the officer sanctioning refund, on demand.
Signature and name (of proprietor/managing partner/ person authorised by
managing director of the SEZ Unit/Developer) with complete address, telephone
and e-mail.
Date: Place: