[THIS FORM SHOULD BE IN TRIPLICATE AS * COUNTERFOIL * DUPLICATE * ORGINAL]

THE CENTRAL SALES TAX

(REGISTRATION AND TURNOVER) RULES, 1957
FORM -C
(FORM OF DECLARATION,See Rule 12(1))

Form Serial No
Name of issuing State

320906/IC/18027/2012

Office of issue

KERALA

Date of issue

CT OFFICE 2ND CIRCLE PALAKKAD

Name and address of the purchasing dealer

in full(to whom issued along with
registration Certificate No)
Date from which Registration is valid

20/07/2013

To (TIN/ Name / Address of seller)

32090650075, VISUVAM AUTOMOBILE, VISUVAM

AUTOMOBILE,7/1412,SUVITHA
COMPLEX,CHANDRANAGAR,PALAKKAD
21/04/2006

State of seller

07070275574 ( GURMEET BEARING CO., 3064/5,GALI

KALYAN SINGH,RAM BAZAR,MORI GATE,DELHI-110006. )

Certified that goods Ordered for in our

purchase order
Supplied as per bill /cash memo / chalan
No & date
Purchased from you as per bill/cash
memo/chalan No
Supplied under your chalan No /dtd
For the purpose of
Covered by my/our registration
certificate No / dated issued under the Ce
Name of the person signing the
declaration.
Status of person signing declaration in
relation to the dealer.

Delhi
,
Details attached as Annexure-A
Details attached as Annexure-A
Details attached as Annexure-A
RESALE
32090650075C, 01/04/2005

B V VISWANATHAN
Propreitor

It is further certified that (I/We am/are not registered under section 7 of the said Act
in the State of Delhi in which the goods covered by this Form are/will be delivered.
The above statements are true to the best of my knowledge and belief (Sign) .........

Particulars of Bill/ Cash memo/ Chalan No, Date and Amount are attached as Annexure-A
Counterfoil retained by the purchasing dealer, duplicate retained by the selling dealer,
Respective Assessing Authorities and dealers can verify these details through official
website of Kerala Commercial Taxes Department (www.keralataxes.gov.in)

Signature Not Verified

Digitally signed by BATLAGUNDU VALIKESWARAN
VISWANATHAN
Date: 2013.07.20 11:51:00 IST
Reason: Statutory form signing
Location: Kerala

[THIS FORM SHOULD BE IN TRIPLICATE AS * COUNTERFOIL * DUPLICATE * ORGINAL]

ANNEXURE -A

Issued By (TIN / Name / State)

Office of issue

Invoice Details

(FORM -C)

32090650075, VISUVAM AUTOMOBILE, VISUVAM

AUTOMOBILE,7/1412,SUVITHA COMPLEX,CHANDRANAGA
CT OFFICE 2ND CIRCLE PALAKKAD

Issued To (TIN / Name / State)

Form Serial No & Date

Delhi

320906/IC/18027/2012 ,

Sl No

Invoice No

Invoice Date

341/342

01-DEC-12

Total

07070275574 ( GURMEET ,
BEARING CO., 3064/5,GA

Value of Goods

20/07/2013

Tax

Total

94962

94962

94,962.00

.00

94,962.00

The above statements are true to the best of my knowledge and belief (Sign) ..........
This document is digitally signed. So manual signature is not required.

Signature Not Verified

Digitally signed by BATLAGUNDU VALIKESWARAN
VISWANATHAN
Date: 2013.07.20 11:51:00 IST
Reason: Statutory form signing
Location: Kerala