Form 65

(See rule 81)

Register of intimations received under sub-section(4) of section  21,  sub-section (4) of section  52,  clause (e a) of sub-section (6) of section 55  or sub-section (17) of section 57 of the Madhya Pradesh Vat Act, 2002.

To, 

The     ___________________________

           ___________________________  

I,_______________________________________(Name of the dealer/transporter) ____________________________________ (Address) holding TIN ___________ (if any) under the Madhya Pradesh Vat Act 2002 hereby give the option for payment of lump-sum under sub-section(4) of section  21 or  under sub-section (4) of section  52 or   clause (e a) of sub-section (6) of section 55  or sub-section (17) of section 57 of said Act in respect of the penalty of Rs. __________(in figures) Rs.__________________(in words) imposed in case no....................for the period from________to________ vide order dated_______. The lump-sum amount of Rs. __________(in figures) Rs.__________________(in words) has been paid vide challan no._____dated__________.

2. I undertake that I shall not challenge the order imposing penalty in any forum.

Place _____________

Date  ______________                                                  

                                                                   Signature of the dealer / transporter

*Strike out whichever is not applicable.