Return of service tax credited to the Government of India for the 
period _______________ to _______________ Collectorate


1. Name of the assessee _____________________
2. Whether an individual or proprietary firm or partnership firm or any other (please specify) ____________________
3. Category of services __________________________

Service Tax Registration No. _____________________



Value of Taxable service charged or billed (indicate break-up of the amount month-wise)

Value of taxable service realised (indicate break-up of the amount month-wise) Amount of service tax payable Amount of service tax adjusted in terms of sub-rule (3) of rule 6 of the Service Tax Rules, 1994 Amount of interest, if any payable
1 2 3 4 5 6
Amount paid Total amount paid {7(a)+7(b)+7(c)} Challan No. and date/Journal Slip No. and date
Service tax paid to the Government credit  Interest paid  Any other amount paid     
7(a) 7(b) 7(c) 8
please specify and enclose documentary evidence

please specify on what account the amount has been paid


I/We declare that the above particulars are in accordance with the records and books maintained by us and are correctly stated.

Place :
Date :

Signature of the assessee or his 
Authorized representative

Assessment Memorandum

1. The service tax has been paid correctly.
2. The service tax has been short/excess paid to the extent of Rs._____________ The correct assessment of the service tax is as per the following details:
The assessee is requested to pay the deficiency of Rs.________ within 10 days from the receipt of this Assessment Memorandum. The assessee may apply for refund, if any, in______________.

(Signature and stamp of the 
Central Excise Officer)