FORM 59-A[See Rule 74-A (3)]

DeclarationOffice of Issue …………………… Date of Issue …………………………………….Name of the dealer to whom issued along with registration No. …………………… Sr. No. Seal if issuing authorityUnder section 45-A of the Chhattisgarh Commercial TaxAct 1994 in respect of goods being imported into orexported out of Chhattisgarh

1. (a) Name and complete address of theconsignor

(b) If consignor is a dealer of Chhattisgarh, hisregistration certificate No. under theChhattisgarh Commercial Tax Act, 1994……………..

2 (a) Name and complete address of consignee (b) In consignor is a dealer of Chhattisgarh, his

registration certificate No. under theChhattisgarh Commercial Tax Act, 1994

3. Name and complete address of the person towhom goods will be delivered, if his consigneeis described as “self” in the declaration

4. Place from which goods dispatched 5. Destination (including District) 6. Brief description of goods 7. Total quantity 8. Total Weight 9. Total Value 10 Consignor’s invoice No. and date 11 (a) Name and full address of the carrier

[Transport company or owner of the vehicles]

(b) Detail of the vehicle, if any, with its number. © Name and address of the driver of the

vehicle

(d) Name and address of the person (if any) incharge of the goods.

I, ………………………………………………declare that to the best of my knowledge andbelief the above statements are true andcorrect.

Place Date Signature of the

Consignor of the goods.(To be completed in the office of the check post) Time of arrival of the vehicle at thecheck post.Time of departure of the vehicle from the check post ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Reasons for abnormal of the vehicle at the check post.

Seal SignatureDate Designation