FORM VAT C-4

(See Rule-20)
CERTIFICATE
(To be submitted by the VAT dealer with the return)
Certified to be issued by selling VAT dealer to a purchasing VAT dealer in respect
of taxable goods for claim of input tax under sub section (3) of section 8.

Haryana Tax
Certified that I / We Krishna Thread Ball Co., Ram Gali, Chotta Bazar, Thanesar, Kurukshetra-136118
payer identification _06882302057_ registered under the VAT Act. 2003 in District Kurukshetra
(i) have paid the full amount of tax under the VAT Act. 2003 vide Challan no Dated
(ii) have adjusted the input tax paid to _ (Name and Complete adress of the selling dealer)
holding TIN-06112313102 on the goods sold to Tilda Riceland Pvt. Ltd. 42KM stone, N.H-8, Delhi Jaipur Highway - Gurgaon
TIN No. : - 06932219046
As per Tax invoices stated below : -
Description of Amount of
Sr. No. Tax Invoice No. A/C Year Taxable Amount
Goods Sold TAX
1 Sewing Thread 52212 19-May-14 35,700.00) 1,874.25)
2 Sewing Thread 52227 27-May-14 24,500.00) 1,286.25)
3 Sewing Thread 52369 04-Dec-14 10,200.00) 535.50)

Total 70,400.00) 3,696.00)

Place : - Kurukshetra Signature of the selling VAT dealer
DATE: - 2014 Name : -
For Krishna Thread Ball Co.

Authorised Signatory