FORM VAT-404
INDEMNITY BOND FOR LOSS OF WAY BILL.
[ See sub-rule (7) of rule 80 ]
I, Sri …………………………………………… son/daughter/wife of Sri …...…………………
residing at ------------------------------------------- P.O. ……………………………P.S.……………….
Dist ……………………………………… , Proprietor/Partner/ (Managing) Director/Manager/Principal
Officer/ Authorised officer of the Business known as ……………………….. situated at
…………………………… …………….and possessing a Tax-payers’ Identification number bearing
TIN
in the State of Orissa under the Orissa Value Added
Tax Act, 2004 , do hereby declare that the way bill form bearing no……………… issued to me/us by
the Sales Tax Officer/ Assistant Commissioner of Sales Tax, …………………. Circle/Range, on
…………………….. is lost/destroyed/stolen,
(i)
(ii)
(iii)
from my custody, before being filled in and signed by me; or
from my custody, after being filled in and signed by me, before despatch to the selling
dealer/consignee, namely ………………………..
in transit, after being duly filled in and signed by me and despatched to the selling
dealer/consignee, namely………………………..
( Strike out whichever is not applicable )
And I, the aforesaid Sri ……………………………do hereby undertake to hold harmless and to
indemnify the Government against any loss arising out of the aforesaid loss of way bill form.
And I bind myself, my heirs, executors, administrators and assignees and each one of the other
person having any share, title or interest in the aforesaid business and his heirs, executors,
administrators and assignee jointly and severally for holding harmless and indemnifying the
Government for any such loss as aforesaid.
Place __________________
Date
Signature of the dealer
__________________
Designation with relation to the business
Seal
191