Form of declaration to be filed by a person who does not have either a permanent account number or General Index Register Number and who makes payment in cash in respect of transaction specified in clauses (a) to (h) of rule 114B

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....;                             Middle Name                                                 Surname                                                 4 Flat/ Room No. 5 Floor No. 6 Name of premises 7 Block Name/No. 8 Road/ Street/ Lane 9 Area/ Locality 10 Town/ City 11 District 12 State 13 Pin code 14 Telephone Number (with STD code) 15 Mobile Number 16 Taxpayer identification Number in the country of residence (if covered by third proviso)   17 Amount of transaction (Rs.)               19 In case of transaction in joint names, number of persons involved in the transaction   18 Date of transaction D D M M Y Y Y Y 20 ....

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....r  (ii)  the applicant is a foreign company covered by the third proviso to Rule 114B and does not have any income chargeable to tax in India.  3.  I also declare that I am making this application for _____________________ in my capacity as __________ (designation) and I am competent to make this application and verify it. [if applicable] Verified today, the ___________day of 20_____.            Place: ___________          (Signature of declarant) Notes: 1.  Before signing the declaration, the declarant should satisfy himself that the information furnished in this form is true, correct and complete in all respects. Any person making a false statement in the declaration shall be liable to prosecution under section 277 of the Income‐tax Act, 1961 and on conviction be punishable,‐ (i)  in a case where tax sought to be evaded exceeds twenty‐five lakh rupees, with rigorous imprisonment which shall not be less than six months but which may extend to seven years and with fine; (ii)  in any other case, with rigorous imprisonment which ....

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.... 3 months old) 22 No Yes 23. Property registration document 23 No Yes 24. Allotment letter of accommodation from Government 24 No Yes 25. Passport of spouse bearing name of the person 25 No Yes 26. Property tax payment receipt (Not more than one year old) 26 No Yes B. For Association of persons (Trusts)         Copy of trust deed or copy of certificate of registration issued by Charity Commissioner. 27 Yes Yes C. For Association of persons (other than Trusts) or Body of Individuals or Local authority or Artificial Juridical Person)         Copy of Agreement or copy of certificate of registration issued by Charity commissioner or Registrar of Cooperative society or any other competent authority or any other document originating from any Central or State Government Department establishing identity and address of such person. 28 Yes Yes  D. For a foreign company       1. Copy of Certificate of Registration or incorporation issued in the country where the applicant is located, duly attested by authorised officials of IFSC banking un....

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....76; Draft/Banker's Cheque, 􀀀 Online transfer, 􀀀 Other 20 Aadhaar Number issued by UIDAI (if available)   21 If applied for PAN and it is not yet generated enter date of application and acknowledgement number D D M M Y Y Y Y 22 If PAN not applied, fill estimated total income (including income of spouse, minor child etc. as per section 64 of Income-tax Act, 1961) for the financial year in which the above transaction is held   a Agricultural income (Rs.)     b Other than agricultural income (Rs.)   23 Details of document being produced in support of identify in Column 1 (Refer Instruction overleaf) Document code Document identification number Name and address of the authority issuing the document 24 Details of document being produced in support of address in Columns 4 to 13 (Refer Instruction overleaf) Document code Document identification number Name and address of the authority issuing the document                                         Verification I, ...................

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.... Yes Yes 10. Certificate of identity/address signed by a Member of Parliament or Member of Legislative Assembly or Municipal Councillor or a Gazetted Officer as per annexure A prescribed in Form 49A 10 Yes Yes 11. Certificate from employer as per annexure B prescribed in Form 49A 11 Yes Yes 12. Kisan passbook bearing photo 12 Yes No 13. Arm's license 13 Yes No 14. Central Government Health Scheme /Ex-servicemen Contributory Health Scheme card 14 Yes No 15. Photo identity card issued by the government./ Public Sector Undertaking 15 Yes No 16. Electricity bill (Not more than 3 months old) 16 No Yes 17. Landline Telephone bill (Not more than 3 months old) 17 No Yes 18. Water bill (Not more than 3 months old) 18 No Yes 19. Consumer gas card/book or piped gas bill (Not more than 3 months old) 19 No Yes 20. Bank Account Statement (Not more than 3 months old) 20 No Yes 21. Credit Card statement (Not more than 3 months old) 21 No Yes 22. Depository Account Statement (Not more than 3 months old) 22 No Yes 23. Property registration document 23 No Yes 24. Allotment letter of accommodation from Government ....