Application for Compounding of Offence

1.            Full Name and address of the applicant:

2.            Address for communication:

3.            (i) Permanent Account Number (PAN):

(ii) Registration No:

4.            Commissioner of Central Excise having jurisdiction over the applicant:

5.            The violation of provisions of Central Excise Act, 1944, against which prosecution

is instituted or contemplated for which application of Compounding:

6.            Details of invoices/Adjudication order in relation to the case for compounding:

7.            Date of seizure, if any:

8.            Brief facts of the case and particulars of the offence(s) charged:

9.            Whether Show Cause Notice issued 10. If yes, details of duty demanded

11.          Whether Show Cause Notice has been adjudicated

12.          If yes, adjudication details

(a)          Amount of duty confirmed

(b)          Amount of CENVAT credit to be recovered/denied

(c)           Fine imposed

(d)          Penalty imposed

12A.       Whether the amount of duty, penalty and interest have been paid and if yes, the details thereof.

13.          Whether this is the first offence under the Central Excise Act, 1944. If not details of previous cases:

14.          Whether any proceedings for the same offence contemplated under any other law, if so the details thereof.

Name and Signature of the applicant.

DECLARATION

1. I shall pay the compounding amount, as may be fixed by the compounding authority under sub-rule (3) of Rule 4 of the Central Excise (Compounding of Offences) Rules, 2005.

2. I understand that I cannot claim, as of right that the offence committed by me under the Act should be compounded.

Name and Signature of the applicant.

VERIFICATION

I, ---------------the son/daughter/wife of---------------- residing at-----------------------------------do solemnly declare that I am making this application in my capacity as---------------------------- and I am competent to verify it.

That the contents of this application are true to the best of my knowledge and belief and no information relevant to the facts of the case has been suppressed. The documents accompanying the application are true copies of the originals and the tables showing financial transactions are correct and are duly attested by me.

Verified today the           day of   (month)               (year) at              .

Name and Signature of the applicant.

Place:

Date: