FORM E
[See rule 5]
Form of appeal to the Commissioner of Wealth-tax (Appeals) under section 23A of the Wealth-tax Act, 1957

Wealth-tax Range………………
† No…………….of………………..
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 appeal 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 Commissioner (Appeals), give the details as to the-                                         
(a) 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 notices may be sent to the appellant  
Signed
(Appellant)
STATEMENT OF FACTS *
GROUNDS OF APPEAL *
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 the form of verification appended thereto shall be signed by a person 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.
7. The memorandum of appeal filed by the assessee shall be accompanied by a fee of two hundred and fifty rupees.
8. The fee should be credited in a branch of the authorised bank or a branch of the State Bank of India or a branch of the Reserve Bank of India after obtaining a challan from the Assessing Officer and a copy of challan sent to the Commissioner of Income-tax (Appeals).