FORMAT

1. Name and address of the assessee or person:

2. Service Tax Code (STC) No. or Registration No. (if any):

3. Constitution of assessee:

(Proprietorship or Partnership or Private Ltd or Public Ltd or Registered Trust or Society or Other (specify))

4. Commissionerate:

5. Division:

6. Details of show cause or demand notice:

7. Amount involved in the show cause notice:

8. Reasons for provisional attachment of property.

9. Address and other details of property;

10. Value of property proposed to be attached:

11. Details of previous offences, if any:

12. Comments, if any:

Date:                                                                                                                 Signatures of Assistant or Deputy Commissioner of Central Excise or Service Tax

(With name and official seal)