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[THIS FORM SHOULD BE IN TRIPLICATE AS * COUNTERFOIL * DUPLICATE * ORIGINAL]

THE CENTRAL SALES TAX

(REGISTRATION AND TURNOVER) RULES, 1957

FORM - C

(FORM OF DECLARATION, See Rule 12(1))

Form Serial No PYC 16 1449124


Name of issuing State U.T. OF PUDUCHERRY

Office of issue OFFICE OF THE CTO - IAC, PUDUCHERRY

Date of issue 13/06/2016

Name and address of the purchasing dealer 34740020329


in full to whom issued along with registration SONA META CHEM PVT LTD
Certificate No R.S. NO 9/13, KARASUR VILLAGE, KADAPERIKUPPAM POST,
PUDUCHERRY-605502

Date from which Registration is valid 01/07/2014

To TIN 36200212844
CST HYR/02/3/2370/99-2000
Name SHYAM PHENO CHEM PVT LTD
Address of seller HYDERABAD

State of seller TELANGANA

Certified that goods ordered for in our


Purchase order no.

Supplied as per Bill / Cash Memo / Chalan Month : January 2016


No. & date Total no of invoices : 1
Value of C-Form : Rs. 115927/-
Purchased from you as per Bill/ Cash Memo
/ Chalan No. (Including Tax value)
For invoice wise details please see Annexure
Supplied under your Chalan No. & dated

For the purpose of

and are covered by my / our registration 34740020329 , Dt.01/07/2014


certificate No / dated issued under the
Central Sales Tax Act, 1956

It is further certified that I/we am/are not registered under section 7 of the said Act in the State of
TELANGANA in which the goods covered by this Form are/will be delivered.

Name and address of the purchasing dealer SONA META CHEM PVT LTD
in full R.S. NO 9/13, KARASUR VILLAGE, KADAPERIKUPPAM POST,
PUDUCHERRY-605502

The above statements are true to the best of my knowledge


and belief.

Date : Signature

Name of the person signing the declaration D K SHARMAA

Status of person signing declaration in MANAGING DIRECTOR


relation to the dealer

NOTE :- Counterfoil - to be retained by the purchasing dealer; Duplicate - to be retained by the selling dealer.
[ Original to be furnished to the prescribed authority in accordance with the rules framed under sec 13(4)(e) by the
appropriate State Government.]
Genuineness of this form can be verified through the official website http://gst.puducherry.gov.in using
web reference number 1963334 or http://www.tinxsys.com
[THIS FORM SHOULD BE IN TRIPLICATE AS * COUNTERFOIL * DUPLICATE * ORIGINAL]

ANNEXURE Invoice wise Details (FORM - C)

Issued By TIN 34740020329


Name SONA META CHEM PVT LTD
Address R.S. NO 9/13, KARASUR VILLAGE, KADAPERIKUPPAM POST,
PUDUCHERRY-605502

Office of issue OFFICE OF THE CTO - IAC, PUDUCHERRY

Issued To TIN 36200212844


CST HYR/02/3/2370/99-2000
Name SHYAM PHENO CHEM PVT LTD
Address HYDERABAD

Form Serial No & Date PYC 16 1449124, 13/06/2016


Sl. Invoice No Invoice Date Description of Commodity Purpose Value of Tax Value of
No. Goods Goods
excluding including
tax tax
1 222 27/01/2016 RESIDUE Mfg. 113654 2273 115927
Mfg. - Manufacture or Processing of goods for sale; Packing. - Packaging of goods for sale/Resale;
Gen. Pow. - Generation or distribution of electricity or any other form of power; Tele. Com. - Telecommunication network;

The above statements are true to the best of my knowledge


and belief.

Signature
Name of the person signing the declaration : D K SHARMAA
Status of person signing declaration in relation to the dealer :MANAGING DIRECTOR