ANNEXURE - A - Income Tax Informants Rewards Scheme, 2018

ANNEXURE-A FORM OF STATEMENT FOR FURNISHING INFORMATION BY INFORMANT REGARDING SUBSTANTIAL TAX EVASION TO THE INCOME TAX DEPARTMENT FOR REWARD AS PER INCOME TAX INFORMANTS REWARD SCHEME. 2018 1. Full name of the informant (of each informant separately if there are more than one informant) (in capital letters) : 2. Father' s name : 3. Date of Birth : 4. Permanent address of the informant(s) : 5. Current address of the Informant(s) (if different from permanent address) : 6. (a) Contact particulars Landline Telephone No. : (b) Mobile No. (c) Email ID, if any 7. Aadhar Number (foreign persons may mention Passport number if not having Aadhar number) (attach copy of Aadhar card or Passport) (of each informant separately if there are more than one informant) : 8. Name/names of person/persons/group in respect of whom the information is furnished (PAN may be mentioned, if known) : 9. Address/Addresses of person/persons/ group in respect of whom the information is furnished : 10. Full particulars of (the information furnished should be specific, reliable and definite. Additional sheet may be attached, if required): : (a) Nature, source and extent of substantial tax evasion (b) Nature, location and estimated value of undisclosed assets (c) Modus operandi of tax evasion (d) Financial Years to which the tax evasion relates 11. Particulars of information/ documents furnished, if any : (a) In original (b) Copy only 12. (a) Source of information:- Whether the information has been acquired personally in the capacity of an employee, relation or partners etc., of the person mentioned at Sl. 8 above : (b) Whether information has been acquired through some other person. If so, his connection with the person at Sl. 8 above 13. (a) List of documents , if any, furnished in support of the information In original : (b) Copy only 14. Is any of the parties involved in the alleged tax evasion related to you? If yes, furnish details. : 15. (a) Briefly state (attach evidence, if any, and attach extra sheet, if required): How you have come to know about the information; : (b) Special efforts, if any, made; (c) Risks and trouble undertaken (d) Expenditure, if any, incurred 16. Informant Code, if any, allotted earlier under this or old Scheme : 17. Preferred mode of payment of reward (Cash/ bank transfer) (in case of foreign persons reward will not be paid by cash) : 18. Particulars of bank account in which payment of reward is to be made (account no., bank name, branch, IFSC code etc details) : 19. In case of multiple informants, share at which reward is to be paid : Name of informants DECLARATION: I/we declare that, a) I/we have read and understood the Income Tax Informants Reward Scheme, 2018 b) I/we accept that mere furnishing of information by me/us does not by itself confer on me/us right to get reward and that I/we may not get any reward at all. I/we would be bound by the decisions that the authority competent to grant reward may take. c) I/we accept that the Government is under no obligation to enter into any correspondence regarding the action taken as a result of my/our information. I/we will be entitled to know only feedback and/or update about whether my/our information has been acted upon and, if yes, whether I am/we are likely to get any reward. d) I/we accept that reward would be an ex-gratia payment which, subject to the scheme, shall be ganted at the absolute discretion of the competent authority. The decision of the authority shall be acceptable to me/us and I/we shall not challenge it in any litigation, appeal, adjudication or arbitration. e) In the event of my death before the reward is paid to me/us, it may be paid to my/our nominee(s) whose particulars (along with share) are as under:- Name of Informant Name(s) and address(es) of the nominee(s) Date of birth (in case of minor, name and address of guardian to be given) Relationship with the informant Share of the nominee(s) Aadhar Card No. /Passport No. (attach copy) f) I/we accept that if the information furnished by me/us is found to be false I/we would be liable to prosecution as per law including under section 182 of the Indian Penal Code, 1860. Date : _______________ Signature of the informant(s):_______________ Place _______________ Left Thumb impression:______________ Aadhar card no. / Passport no. (Attach copy): ________ [Note: If the information is given by more than one informant, the particulars of all such informants are to be captured and this declaration is to be signed by all such informants.] Signature of the JDIT (Inv) before whom the statement is signed _____________________________________ Name Designation of the Officer with Seal Date:_____________________________ Place: ____________________________ Code No. allotted to the informant Signature of the authority allotting Informant Code _________________________________ Name Designation of the Offcer with Seal Date:__________________________ Place: __________________________