Form 1 - Form of declaration under section 199C of the finance act, 2016, in respect of the taxation and investment regime for Pradhan mantri garib kalyan yojana rules,2016 - Taxation and Investment Regime for Pradhan Mantri Garib Kalyan Yojana Rules, 2016

1 [Form 1 [ See rule 3 (1)] FORM OF DECLARATION UNDER SECTION 199C OF THE FINANCE ACT, 2016, IN RESPECT OF THE TAXATION AND INVESTMENT REGIME FOR PRADHAN MANTRI GARIB KALYAN YOJANA RULES, 2016 To, The Principal Commissioner/Commissioner Madam/ Sir, I hereby make a declaration under section 199C of the Finance Act, 2016. I give below the necessary particulars: 1. Name of the declarant . ...... 2. Address: Office . .... Telephone No .. .................................... Residence ................ ................... Mobile No. .Telephone ...............E-mail ........ 3. Permanent Account Number (PAN) (In case PAN is not held, please apply for PAN and quote the date of application and acknowledgment number) .. 4. Aadhaar Number issued by UIDAI (if available) .. 5. Status of the declarant (a) Whether individual, HUF, firm, company etc. (b) Whether Resident/Non-Resident/Not ordinarily resident .. .. 6. Filing status (a)Whether the declaration (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) . __is original __or revised (__/__/____) .. 7. (a) Total amount of undisclosed income declared (b) Out of (a) above:- (i) Amount held in cash (ii) Details of amount deposited in a bank account/post office account etc. .. Rs .. .. Sl. No. Account number Name of Bank/ Post office etc. Branch name IFSC code/ any other identity code Amount (in Rs.) Total 8. Tax payable thereon [@ 30% of item 7(a) Rs. .. . .. . 9. Surcharge payable thereon (@ 33% of item 8) Rs. .. . .. . 10. Penalty payable thereon [@10% of item 7(a)] Rs. .. . .. . 11. Total of tax, surcharge and penalty payable (8+9+10) Rs. .. . .. . 12. Details of amount paid on or before the date of declaration (Attach proof of payment and provide details below) Rs. .. . .. . Sl. No. BSR Code of Bank Date of Deposit (DD/MM/YYYY) Serial Number of Challan Amount (Rs) (1) (2) (3) (4) (5 ) 13. Details of amount deposited in Pradhan Mantri Garib Kalyan Deposit Scheme, 2016 (Attach proof of deposit and provide details below) (i) Amount deposited [Minimum deposit amount is 25% of item 7(a)] (ii)Date of deposit (iii)Acknowledgement/deposit reference number (iv)Name and details of branch of the entity in which deposit is made Rs. . .. ... . . .. . . .. . . .. . . .. VERIFICATION I son/daughter/wife of Shri ............. (Full name in block letters) (Name of father/husband) hereby solemnly declare that- (a) the information given in this declaration is correct and complete to the best of my knowledge and belief; (b) the provisions of clause (a) of section 199-O of the Finance Act, 2016 in respect of Conservation of Foreign Exchange and Prevention of Smuggling Activities Act, 1974 are not applicable to me; (c) the provision clause (b) of section 199-O 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, Prohibition of Benami Property Transactions Act, 1988 and the Prevention of Money Laundering Act, 2002 are not applicable to me; (d) I am not notified under section 3 of the Special Court (Trial of Offences Relating to Transactions in Securities) Act, 1992; (e) the income declared is not chargeable to tax under the Black Money (Undisclosed Foreign Income and Assets) and Imposition of Tax Act, 2015; I further declare that I am making this declaration in my capacity as (Designation) and that I am competent to make this declaration and verify it. (Signature) Place . Date .. ********************** Notes:- 1. Inserted vide NOTIFICATION No. 116/2016 dated 16-12-2016