FORM OF DECLARATION UNDER SECTION 183 OF THE FINANCE ACT, 2016, IN RESPECT OF THE INCOME DECLARATION SCHEME, 2016

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...................................................................................................................................... Mobile No. .........................Telephone No...................................... 2.  Filing status (a) Whether the declaration ___is original  ___or revised (b) If revised-     (i) Enter receipt No. and Date of filing original Form-1 ......................       /     /                         (DD/MM/YYYY) (ii) Reasons for revised declaration (not exceeding 100 words) ...........................] 3. Permanent Account Number (PAN) ...................................... (In case PAN is not held, please apply for PAN and quote here) 4. Status of the declarant (a) Whether individual, HUF, firm, company etc. ..................................... (b) Whether Resident/Non-Resident/Not ordinarily resident ..................................... 5. Details relating to assessment years for which the declaration is being made: Assessment year Whether return of income filed....

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....the declaration is made, income of other persons in respect of which I am chargeable to tax and income accruing or arising from the assets held by me through any other person for which I had failed to furnish a return under section 139 of the Income-tax Act, 1961 which I had failed to disclose in a return of income furnished by me before the commencement of the Scheme/which has otherwise escaped assessment, has also been disclosed in this declaration; (c) the income of any other person in respect of which I am not chargeable to tax has not been included in this declaration; (d) the provisions of clause (a) of section 196 of the Finance Act, 2016 in respect of Conservation of Foreign Exchange and Prevention of Smuggling Activities Act, 1974 are not applicable to me; (e) the provision clause (b) of section 196 of the Finance Act, 2016 in respect of Indian Penal Code, the Narcotic Drugs and Psychotropic Substances Act, 1985, the Unlawful Activities (Prevention) Act, 1967, the Prevention of Corruption Act, 1988 are not applicable to me; (f) the undersigned has not been notified under section 3 of the Special Court (Trial of Offences Relating to Transactions in Securities) Act,....

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....vestment in asset Yes No III. If reply to (II) above is Yes, furnish description of undisclosed income declared in the form of investment in assets (Use separate sheet in case of multiple assets in the same category) 3[1. Immovable property (attach valuation report) (i) Nature of property (land/building/flat etc.)   ________________ (ii) Address of the property ________________ (iii) Name(s) under which held ________________ (iv) Date of acquisition ________________ (v) Cost of acquisition as per rule 3(1)(d)(I)   ________________ (vi) Value as estimated by the registered valuer on 1st June, 2016 as per rule 3(1)(d)(II)  ________________ (vii) Value as per proviso to Rule 3(1)(d)   Identification number and date of the registered deed Value adopted for stamp duty, if property is acquired on or after 01.04.1981 Fair market value as on 01.04.1981, if property acquired before 01.04.1981 Indexed value of the property as on 01.06.2016         (viii) Fair market value as per rule 3 ________________] 2. Jewellery (attach valuation report) (a) Gold (I) Purity ________, Weight _________, Value ____________ (II) P....

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....__   (iv) Date(s) of acquisition  __________________   (v) Value as determined under Rule 3(1)(c)(II)(ii) __________________   (vi) Fair Market value as per Rule 3 __________________ (c) Unquoted shares and securities other than equity shares in a company [Rule 3(1)(c)(III)] (attach valuation report)   (i) Description of share/security     (A) Name of issuer  __________________   (B) Number of securities/shares  __________________   (C) Type of security/share __________________   (ii) Name(s) under which held __________________   (iii) Cost of acquisition  __________________   (iv) Date(s) of acquisition __________________   (v) Value as determined under Rule 3(1)(c)(III)(ii)  __________________   (vi) Fair Market value as per Rule 3 __________________   5. Any other asset     (i) Description of asset __________________   (ii) Name(s) under which held __________________   (iii) Cost of acquisition/ investment __________________   (iv) Date of acquisition/ investment __________________ &nb....