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(3) Address of Tax Payer : 54/2, Matuail Dokkhin Para , Jatrabari P.S, Dhaka 1362
Goods/Service Not Admissible for Credit (Taxpayers who sell ONLY Local Purchase 21 - Sub-form
Exempted / Specific VAT and Goods/Service Other than Standard
Rate/Credits not taken within stipulated time) Import 22 2,543,349.07 228,839.00 Sub-form
Total Input Tax Credit 23 2,543,349.07 228,839.00
Page 1 of 13
Part-5: INCREASING ADJUSTMENTS (VAT)
Adjustment Details Note VAT Amount
Due to VAT Deducted at Source by the Supply receiver 24 o Sub-form
Payment Not Made Through Banking Channel 25
Issuance of Debit Note 26
Any Other Adjustments (please specify below) 27
Total Increasing Adjustment 28 -
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Part-10: CLOSING BALANCE
Item Note Amount
Closing Balance (VAT) [58-(50+67) + The refund amount not approved] 65 (280,500.00)
Closing Balance (SD) [59-(51+68) + The refund amount not approved] 66 -
Part-11: REFUND
I am interested to get refund of my Closing Balance Items Note Yes No
Requested Amount for Refund (VAT) 67
Requested Amount for Refund (SD) 68
Part-12: DECLARATION
I hereby declare that all information provided in this Return Form are complete, true & accurate. In case of any untrue/incomplete statement, I may be subjected to
penal action under The Value Added Tax and Supplementary Duty Act, 2012 or any other applicable Act prevailing at present.
Page 3 of 13
Sub Form (For Note No-1,2,3,4,5,6,7,10,11,12,13,14,15,16,17,19,20,21 and 22 )
SL No Commercial description of Good/Service Goods/Service Code Goods/Service Name Value (a) SD(b) VAT(c) Notes
Anesthesia Machine M-Caelus Lite 90189090 Anesthesia Machine M-Caelus Lite 1,438,055 300,000 7
Syringe pump Syringe pump 3,240,000 245,000 7
Defibrillator Defibrillator 500,000 35,000 7
Total 5,178,055 580,000
ENT Treatment Unit with complete system 90181990 ENT Treatment Unit with complete syste 1,438,055 9,783 17
Syringe pump Syringe pump 527,540 81,390 17
Infulsion pump Infulsion pump 291,124 43,866 17
Defibrillator/Monitor(Eng. Version)with stadard accessories Defibrillator 580,607 95,735 17
Total 2,837,325 230,774 16
Syringe pump Syringe pump 900,000
Total 900,000
Sub Form (For Note No-1,2,3,4,5,6,7,10,11,12,13,14,15,16,17,19,20,21 and 22 )
SL No Commercial description of Good/Service Goods/Service Code Goods/Service Name Value (a) SD(b) VAT(c) Notes
ENT Treatment Unit with complete system 90181990 ENT Treatment Unit with complete syste 4,300,000 300,000 7