You are on page 1of 3

FORM - XXXIX

Department of Commercial Taxes, Government of Uttar Pradesh


[See rule-57(1)(a) of UPVAT Rules, 2008]
Form of declaration for import-For other than registered dealer
(Counter foil)
Date of issue..

Serial No..
Name and full address of the
dealer to whom form issued

[Seal of the issuing authority][Circle/Sector]


[The above entries to be filled in by the issuing authority]
I, ------------------------------------------------------------- S/o, D/o, W/o -----------------------------------------------,
the authorized signatory of the above named dealer; do hereby declare that the goods noted below are being
imported/received/brought by the aforesaid dealer.

1.

Description of goods

2.
3.
4.
5.

Weight/Measure
Quantity
Value in figure
Value in words

6.
7.

Bill/cash memo/ challan/tax invoice number & date


Name and address of
seller / consigner

8.

TIN
I further do hereby declare that the above information is correct and complete to the best of my knowledge
and belief.

Counter signature by seller /consignor


Seal, name and address
of seller /consignor

1.

Name & address of the


Transporter / carrier etc.

2.
3.
4.

Service Provider no. of the carrier, if any


Carrier/ Truck no.
Name & address of Driver

5.
6.

Driving License No.


Signature of the vehicle driver.

Signature of authorized signatory

FORM - XXXIX
Department of Commercial Taxes, Government of Uttar Pradesh
[See rule-57(1)(a) of UPVAT Rules, 2008]
Form of declaration for import-For other than registered dealer
(Second copy-for carrier)
Serial No..

Date of issue..

Name and full address of the


dealer to whom form issued

[Seal of the issuing authority] [Circle/Sector]


[The above entries to be filled in by the issuing authority]
I, ------------------------------------------------------------- S/o, D/o, W/o -----------------------------------------------,
the authorized signatory of the above named dealer; do hereby declare that the goods noted below are being
imported/received/brought by the aforesaid dealer.

1.

Description of goods

2.
3.
4.
5.

Weight/Measure
Quantity
Value in figure
Value in words

6.
7.

Bill/cash memo/ challan/tax invoice number & date


Name and address of
seller / consigner

8.

TIN
I further do hereby declare that the above information is correct and complete to the best of my knowledge
and belief.

Counter signature by seller /consignor


Seal, name and address
of seller /consignor

1.

Name & address of the


Transporter / carrier etc.

2.
3.
4.

Service Provider no. of the carrier, if any


Carrier/ Truck no.
Name & address of Driver

5.
6.

Driving License No.


Signature of the vehicle driver.

Signature of authorized signatory

FORM - XXXIX
Department of Commercial Taxes, Government of Uttar Pradesh
[See rule-57(1)(a) of UPVAT Rules, 2008]
Form of declaration for import-For other than registered dealer
(Original copy)
Date of issue..

Serial No..
Name and full address of the
dealer to whom form issued

[Seal of the issuing authority][Circle/Sector]


[The above entries to be filled in by the issuing authority]
I, ------------------------------------------------------------- S/o, D/o, W/o -----------------------------------------------,
the authorized signatory of the above named dealer; do hereby declare that the goods noted below are being
imported/received/brought by the aforesaid dealer.

1.

Description of goods

2.
3.
4.
5.

Weight/Measure
Quantity
Value in figure
Value in words

6.
7.

Bill/cash memo/ challan/tax invoice number & date


Name and address of
seller / consigner

8.

TIN
I further do hereby declare that the above information is correct and complete to the best of my knowledge
and belief.

Counter signature by seller /consignor


Seal, name and address
of seller /consignor

1.

Name & address of the


Transporter / carrier etc.

2.
3.
4.

Service Provider no. of the carrier, if any


Carrier/ Truck no.
Name & address of Driver

5.
6.

Driving License No.


Signature of the vehicle driver.

Signature of authorized signatory

You might also like