[Form 3

[See rule 4(2)]

FORM OF REPORTING THE PAYMENT UNDER SUB-SECTION (3) OF SECTION 214 OF THE FINANCE ACT, 2016 (28 OF 2016) IN RESPECT OF INDIRECT TAX DISPUTE RESOLUTION SCHEME, 2016

[IN DUPLICATE]

To,

The Designated Authority

.

.

Sir/Madam,

Please refer to the declaration made by me in Form 1 dated ., and the acknowledgement issued by you in Form 2, vide your Reference No. dated

As required I have deposited the amounts as follows on .