FORM NO. 5
EXPENDITURE-TAX
[See rule 7]
Appeal to the Commissioner of Income-tax (Appeals) under section 22 of the
Expenditure -tax Act, 1987

Designation of the Commissioner (Appeals)
No. of .
1. Name and address of the appellant
2. Permanent Account No.
3. Assessment year in connection with which the appeal is
preferred
4. Assessing Officer passing the order appealed against
5. Section and sub-section of Expenditure-tax Act, 1987,
under which the Assessing Officer passed the order
appealed against and the date of such order
6. Where the appeal relates to any assessment or penalty or
fine, the date of service of the relevant notice of demand
7. In any other case, the date of service of the intimation of the
order appealed against
8. Relief claimed in appeal
9. Address to which notices may be sent to the appellant
Signed (Appellant)
STATEMENT OF FACTS
GROUNDS OF APPEAL
Signed (Appellant)
Verification
I, the appellant, do hereby declare that what is stated above is true to the best of my information and belief.
Verified today, the day of
Place .
Signed (Appellant)
Notes :
1. The form of appeal, ground of appeal and form of verification appended thereto should be signed by a person in accordance with the provisions of rule 7(2).
2. This memorandum of appeal, statement of facts and the grounds of appeal must be in duplicate and shall be accompanied by a copy of the order appealed against and the notice of demand in original, if any, and fee of two hundred and fifty rupees, in case of an appeal by the assessee. It is suggested that the fee should be credited in a branch of the authorised bank or a branch of the State Bank of India or a branch of the Reserve Bank of India after obtaining a challan from the Assessing Officer and a copy of challan sent to Commissioner of Income-tax (Appeals).
3. Delete inappropriate words.
4. These particulars will be filled in the office of the Commissioner (Appeals).
5. If the space provided herein is insufficient, separate enclosures may be used for the purpose.