[This Declaration form can be printed in Triplicate as *Counterfoil * Duplicate * Original]

THE CENTRAL SALES TAX

(Registration & Turnover) Rules 1957
FORM "C"
FORM OF DECLARATION [See rule 12(1)]

Serial No. : 241038435511321

Name of Issuing State : Gujarat Signature Not

Verified
SEAL of Issuing Authority :
Digitally signed by
Office of Issue : Commercial Tax MR L J PARMAR
Date: 2013.03.04
Date of Issue : 01/03/2013 09:30:10 IST

This form of Declaration is valid only for the following:

(1) Period : 01/10/2012 - 31/12/2012
(2) Total Invoices : 1
(3) Total Value : Rs. 3693

Name, Registration Certificate No. and Address of the Purchasing Dealer to whom issued
WELSPUN INDIA LIMITED - 24750400336, Gujarat
SURVE NO 76,MORAI,MORAI,MORAI,PARDI,VALSAD-396191

Date from which registration is valid : 01/01/1997

To,
Name of Registration no. and address of the seller with name of the State
27250546745 - A J BELTINGS - Maharastra

Certified that the goods ordered for in our purchase order No ...................... dated ..................... and
supplied as per Bill/Cash memo/Challan No. .................. dated ..................... as stated below purchased
from you as per Bill/cash memo/Challan No.....................dated...............as stated below are for
resale...................use in manufacture/processing of goods for sale use in mining use in
generation/distribution of power-packing of goods for sale/resale and are covered by my/our registration
certificate No...................dated...............issued under the Central Sales tax Act, 1956.

It is further certified that I/we am/are not registered under section 7 of the said Act in the State of
............................................ 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.
Name and Signature of the person signing the declaration

Date:
Status of the person signing the declaration in relation to the dealer ...............................................................
....................................................................................
...........................................................................................................................................................................
.
# Particulars of Bill/Cash Memo/ Challan:
Date ........................................... No. ................................................. Amounts(Rs.) ......................................

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 [This Declaration form can be printed in Triplicate as *Counterfoil * Duplicate * Original]
Annexure A: TRANSACTION DETAILS IN RELATION TO FORM C
Form Serial No. : 241038435511321
Office of Issue : Commercial Tax, Gujarat
Name of the purchasing dealer to whom issued : WELSPUN INDIA LIMITED
Registration of purchasing dealer to whom issued : 24750400336

To
a) Name of the seller A J BELTINGS
b) Name of the state Maharastra
c) TIN of the seller 27250546745
Sr No. Invoice No Invoice Date Value of Goods Tax Total
1 EXT407 11/10/2012 3622 71 3693
Total Amount : Rs. 3693
The above statements are true to the best of my knowledge and belief.
Signature
Name of the person signing the declaration

Status of the person signing the declaration in relation to the dealer

Date

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