FORM GST DRC - 03

[See rule 142(2)&142(3)]

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Intimation of payment made voluntarily or made against the show cause notice (SCN) or statement

ARN :AD2906220068234 Date :17/06/2022

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1. GSTIN 29CMHPS4949B2ZM
2. Name SUNDAR RAJ SURAJ KUMAR
3. Cause of Payment Voluntary
4. Section under which voluntary payment is made 125

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5. Details of show cause notice, if payment is made within 30 days of Reference No:NA Date Of issue:NA
its issue
6. Financial Year 2022-2023

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7. Details of payment made including interest and penalty, if applicable (Amount in Rs.)
Sr. Tax Period Act Place of Tax/Cess Interest Penalty,if Fee Others Total Ledger Debit entry no. Date of
No. supply applicabl utilised debit entry
e (Cash/credit

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)
1. JUN 2022- CGST Karnataka 0.00 0.00 2,500.00 0.00 0.00 2,500.00 Cash DC290622009 17/06/2022
JUN 2022 4911
2. JUN 2022- SGST Karnataka 0.00 0.00 2,500.00 0.00 0.00 2,500.00 Cash DC290622009 17/06/2022
JUN 2022 4911

8. Reasons, if any -
penalty order U/S 125 not display GSTIN on the name board
9. Verification -

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I hereby solemnly affirm and declare that the information given hereinabove is true and correct to the best of my knowledge and belief and
nothing has been concealed therefrom .

Signature of Authorized Signatory

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Name: Sundar Raj Suraj Kumar
Designation: Proprietor

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Date: 17/06/2022