FORM 5 - Certificate under section 31 or 33 of the Black Money (Undisclosed Foreign Income and Assets) and Imposition of Tax Act, 2015 - Black Money (Undisclosed Foreign Income and Assets) and Imposition of Tax Rules, 2015

Form 5 [ See rule 8] Certificate under section 31 or 33 of the Black Money (Undisclosed Foreign Income and Assets) and Imposition of Tax Act, 2015 Office of the TRO . Dated the ... To (PAN) 1. * This is to certify that a sum of Rs. ..has become due from you on .. in the status of ., details of which are given on the reverse. Whereas a certificate bearing Serial Number dated .. had been forwarded by the Tax Recovery Officer, ...., for the recovery of the sum of Rs .. [name of the place] details of which are given on the reverse and the said Tax Recovery Officer has sent a certified copy of the said certificate to the undersigned under section 33(2) of the Black Money (Undisclosed Foreign Income and Assets) and Imposition of Tax Act, 2015 specifying a sum of Rs .. which is to be recovered from you. 2. You are hereby directed to pay the above sum within 15 days of the receipt of this notice failing which the recovery shall be made in accordance with the provisions of section 31 to section 39 of the Black Money (Undisclosed Foreign Income and Assets) and Imposition of Tax Act, 2015 and the Second Schedule to the Income-tax Act, 1961 and the rules made thereunder. 3. In addition to the sums aforesaid, you will also be liable for all costs, charges and expenses incurred in respect of the services of this notice and of warrants and other processes and all other proceedings taken for realising the arrears. SEAL .... Tax Recovery Officer *Score out whichever paragraph is not applicable. DETAILS OF AMOUNT IN ARREARS Amount (Rs.) Asst. year 1. Tax 2. Penalty u/s 3. Interest u/s 4. Any other sum (give details) 5. Total