[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 .