Appeal to the Commissioner (Appeals) Designation of the Commissioner (Appeals)

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.... *No..............of 20........................... 1. Name and address of the appellant    2. Permanent Account Number   3. Assessment year in connection with which the appeal is preferred   4. Assessing Officer passing the order appealed against   5. Section and sub-section of the Black Money (Undisclosed Foreign Income and Assets) and Imposition of Tax Act, ....

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....s of date of payment, challan number and amount paid)   12. **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 passing....

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....gned (Appellant) STATEMENT OF FACTS GROUNDS OF APPEAL ........................... Signed (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. Verified today the ........................... day of ........................... Place ............. .......................