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 :AD290124022041S Date :17/01/2024

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1. GSTIN 29AODPC4191B1ZB
2. Name BELAGODU NAGENDRA PRASAD CHARITHA
3. Cause of Payment Voluntary
4. Section under which voluntary payment is made 73(5)

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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 2023-2024

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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. APR 2023- CGST Karnataka 112,158. 0.00 0.00 0.00 0.00 112,158. Credit DI290124012 17/01/2024
NOV 2023 00 00 9499
2. APR 2023- SGST Karnataka 102,472. 0.00 0.00 0.00 0.00 102,472. Credit DI290124012 17/01/2024
NOV 2023 00 00 9499

8. Reasons, if any -
Reversal of ITC
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: BELAGODU CHARITHA
Designation: Proprietrix

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Date: 17/01/2024