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[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
Office of issue
Date of issue
Name and address of the purchasing dealer
in full(to whom issued along with
registration Certificate No)
Date from which Registration is valid
To (TIN/ Name / Address of seller)

State of seller
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.

320906/IC/12238/2012
KERALA
CT OFFICE 2ND CIRCLE PALAKKAD
30/03/2013
32090650075, VISUVAM AUTOMOBILE, VISUVAM
AUTOMOBILE,7/1412,SUVITHA
COMPLEX,CHANDRANAGAR,PALAKKAD
21/04/2006
33301803593 ( SOUTHERN AUTO PRODUCT ENGINEERS,
KOVAI )
Tamil Nadu
,
Details attached as Annexure-A
Details attached as Annexure-A
Details attached as Annexure-A
RESALE
32090650075C, 01/04/2005

VISWANATHAN
Propreitor

It is further certified that (I/We am/are not registered under section 7 of the said Act
in the State of Tamil Nadu 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 11:45:59 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

33301803593 (
SOUTHERN AUTO PRODUCT

Tamil Nadu

320906/IC/12238/2012 ,

Sl No

Invoice No

Invoice Date

750

08-DEC-12

2562

2562

752

08-DEC-12

2660

2660

743

05-DEC-12

3193

3193

754

12-DEC-12

7160

7160

741

03-DEC-12

11444

11444

27,019.00

.00

27,019.00

Total

Value of Goods

30/03/2013

Tax

Total

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 11:45:59 IST
Reason: Statutory form signing
Location: Kerala