FORM E
[See rule 5]
Form of appeal to the Deputy Commissioner (Appeals) and Commissioner of wealth-tax (Appeals) under section 23 of the wealth-tax Act, 1957
Wealth-tax Range ......................................................
! No. ...................................... of .............................. 19 ..... 19......

Name and address of the appellant Permanent Account Number		
		
Assessment year in connection with which the appeal is preferred 		
		
Assessing Officer /Valuation Officer passing the order appealed against.		
		
Where valuation of any asset has been referred to the Valuation Officer, designation and address of such valuation officer		
		
Section and sub-section of the Wealth-tax Act, 1957, under which the Assessing Officer Valuation Officer passed the order appealed against and the date of such order.		
		
Where the appealed relates to any assessment, penalty/fine, the date of service of the relevant notice of demand		
		
In any other case, the date of service of the intimation of the order appealed against		
		
Section of the Wealth-tax Act, 1957, under Which the appeal is preferred		
		
Where return has been filed by the appellant for the assessment year in connection with which the appeal is preferred, whether tax due on the net wealth returned has been paid in full. (If the answer is in the affirmative, give details of the date of payment and amount paid.)		
		
*Relief claimed in appeal		
		
**Where an appeal in relation to any other assessment year is pending in the case of the appellant with any Deputy Commissioner (Appeals) /Commissioner (Appeals), Give the details as to the date----		
		
(a)	Deputy Commissioner (Appeals ) /Commissioner (Appeals) with whom the appeal is pending ;		
		
(b)	Assessment year in connection with which the appeal has been preferred;		
		
(c)	Assessing Officer/Valuation Officer passing the order appealed against;		
		
(d)	Section and sub-section of the Act, under which the Assessing Officer/Valuation Officer passed the order appealed against and the date of such order 		
		
Address to which notice may be sent to the appellant		
		
	............................................................	
Statement of Facts*	Signed	
Grounds of Appeal*	(Appellant)	

Form of verification
I, ...................................................................................... the appellant, do hereby declare that what is stated above is true to the best of my information and belief.

Date ...........................							...........................................
Place ..........................								Signature 
									...........................................
									Status of Appellant
Notes :
1.	The form of appeal, grounds of appeal and form of verification appended thereto shall be signed by a perosn in accordance with the provisions of section 15A of the Wealth-tax Act, 1957.
2.	The memorandum of appeal, statement of facts and the grounds of appeal must be in duplicate and should be accompanied by a copy of the order appealed against and the notice of demand in original, if any.
3.	Delete the inappropriate words.
4.	The particulars will be filled in in the office of the Deputy Commissioner (Appeals)/Commissioner(Appeals).
5.	*If the space provided herein is insufficient , separate enclosures may be used for the purpose.
6.	**if appeals are pending in relation to more than one assessment year, separate particulars in respect of each assessment year may be given.