FORM 6 - Tax compliance for undisclosed foreign asset - Black Money (Undisclosed Foreign Income and Assets) and Imposition of Tax Rules, 2015

Form 6 Tax compliance for undisclosed foreign asset [ See rule 9(1)] Form of declaration of undisclosed asset located outside India under section 59 of the Black Money (Undisclosed Foreign Income and Assets) and Imposition of Tax Act, 2015 To, The Principal Commissioner/Commissioner Sir/ Madam, I hereby make a declaration under section 59 of the Black Money (Undisclosed Foreign Income and Assets) and Imposition of Tax Act, 2015. I give below the necessary particulars: 1. Name of the declarant . 2. Address: Office .. E-mail Telephone No .. Residence E-mail Telephone No .. .... 3. Permanent Account Number (PAN) . . (In case PAN is not held, please apply for PAN and quote here) 4. Original/Revised declaration . . (If Revised provide date of filing original declaration) 5. Status of the declarant (a) State whether individual, HUF, firm, company etc. . . (b) State whether Resident/Non-Resident/Not ordinarily resident . . 6. Whether any Income-tax return has been filed? Yes/No. If Yes provide the following details (a) Asst. Year for which last return filed . . (b) Assessing Officer before whom filed, if above return filed in paper form . . 7. Statement of undisclosed asset located outside India (as per annexure) 8. Total amount of declaration of undisclosed asset located outside India Rs . . 9. Tax payable thereon (@ 30% of item 8) Rs . . 10. Penalty payable thereon (@ 30% of item 8) Rs . . 11. Tax paid, if any, on or before the date of declaration Rs . . (Attach proof of payment and provide details below) Sl BSR Code of Bank Date of Deposit (DD/MM/YYYY) Serial Number of Challan Amount (Rs) (1) (2) (3) (4) (5) i ii 12. Balance tax payable ... VERIFICATION I son/daughter/wife of Shri ................. (Full name in block letters) (name of father/husband) solemnly declare that (a) the information given in this declaration is correct and complete to the best of my knowledge and belief; (b) my own undisclosed foreign asset and also any undisclosed foreign asset of other persons in respect of which I am chargeable to tax and income accruing or arising from 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 Act/which has otherwise escaped assessment, has been disclosed in this declaration; (c) the provisions of section 71(a) in respect of Conservation of Foreign Exchange and Prevention of Smuggling Activities Act, 1974 are not applicable to me; (d) the provision of section 71(b) 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; (e) the undersigned has not been notified under section 3 of the Special Court (Trial of Offences Relating to Transactions in Securities) Act, 1992; (f) the asset declared has not been acquired from income chargeable to tax under the Income-tax Act for any previous year relevant to assessment year,- (i) where a notice under section 142 or sub-section (2) of section 143 or section 148 or section 153A or section 153C of the Income-tax Act has been received in respect of such assessment year and the proceeding is pending before the Assessing Officer; (ii) where a search has been conducted under section 132 or requisition has been made under section 132A or a survey has been carried out under section 133A of the Income-tax Act in a previous year and a notice under sub-section (2) of section 143 of the said Act for the assessment year relevant to such previous year or a notice under section 153A or under section 153C of the said Act for an assessment year relevant to any previous year prior to such previous year has not been received and the time for issuance of such notice has not expired. 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 .. * Score out whichever is not applicable. Annexure to Form 6 Statement of undisclosed assets located outside India Description of assets declared (Use separate sheet in case of multiple assets in the same category) 1. Bank account (a) Name and address of Bank ________________ (b) Country of location ________________ (c) Account holder name(s) ________________ (d) Account Number ________________ (e) Account opening date ________________ (f) Sum of all credits in the account ________________ (g) Fair market Value as per Rule 3 ________________ (Provide separate computation if different from (f)) 2. Immovable property (attach valuation report) (a) Nature of property (land/building/flat etc.) ________________ (b) Address of the property ________________ (c) Country of location ________________ (d) Name(s) under which held ________________ (e) Date of acquisition ________________ (f) Total acquisition cost ________________ (g) Value as estimated by the valuer on valuation date ________________ (h) Fair Market value as per Rule 3 ________________ (Provide separate computation if different from (f) or (g)) 3. Jewellery (attach valuation report) (a) Gold (I) Purity ________, Weight _________, Value ____________ (II) Purity ________, Weight _________, Value ____________ (b) Diamond (1 carat or more) (I) Carat ________, Cut _______, Colour ______, Clarity_______, Value ________ (II) Carat ________, Cut _______, Colour ______, Clarity_______, Value ________ (c) Diamond (less than 1 carat) and other precious stones Value __________ (d) Other precious metals Value__________ 4. Artistic work (attach valuation report) (a) Nature of artistic work __________________ (b) Country of location __________________ (c) Name(s) under which held ________________ (d) Date of acquisition __________________ (e) Cost of acquisition __________________ (f) Value of artistic work as estimated by the valuer __________________ (g) Fair Market value as per Rule 3 ________________ (Provide separate computation if different from (e) or (f)) 5. Shares and securities (a) Quoted shares and securities [Rule 3(1)(c)(I)] (i) Description of security/share (A) Name of issuer __________________ (B) Number of securities/shares __________________ (C) Type of security/share __________________ (ii) Established securities market where quoted __________________ (iii) Country where securities market located __________________ (iv) Name(s) under which held __________________ (v) Cost of acquisition __________________ (vi) Date(s) of acquisition __________________ (vii) Value as determined under Rule 3(1)(c)(I) __________________ (viii) Date of valuation __________________ (ix) Fair Market value as per Rule 3 __________________ (Provide separate computation if different from (v) or (vii)) (b) Unquoted equity share [Rule 3(1)(c)(II)] (attach valuation report) (i) Description of share (A) Name of issuer __________________ (B) Number of shares __________________ (C) Type of share __________________ (ii) Country of location __________________ (iii) Name(s) under which held __________________ (iv) Cost of acquisition __________________ (v) Date(s) of acquisition __________________ (vi) Value as determined under Rule 3(1)(c)(II) __________________ (vii) Date of valuation __________________ (viii) Fair Market value as per Rule 3 __________________ (Provide separate computation if different from (iv) or (vi)) (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) Country of location __________________ (iii) Name(s) under which held __________________ (iv) Cost of acquisition __________________ (v) Date(s) of acquisition __________________ (vi) Value as determined under Rule 3(1)(c)(III) __________________ (vii) Date of valuation __________________ (viii) Fair Market value as per Rule 3 __________________ (Provide separate computation if different from (iv) or (vi)) (6) Any other asset (a) Description of asset __________________ (b) Country of location __________________ (c) Name(s) under which held __________________ (d) Value as determined under Rule 3(1) __________________ (e) Date of valuation __________________ (f) Fair Market value as per Rule 3 __________________ (Provide separate computation if different from (d)) (7) Total fair market value of all the assets declared __________________ (8) Deduction as per section 5 of the Act ___________________ (where part of asset acquired from income already assessed under the Income-tax Act) (to be provided in respect of each asset separately) (9) Deduction on account of investment made in the asset during the previous year relevant to the assessment year for which a notice u/s 142/143(2)/148/153A/153C of the I.T. Act is issued ___________________ (10) Total fair market value of all the undisclosed assets declared (7-8-9) ____________________ (to be taken to item 8 of the form) (Signature) (Name) Place . Date . Notes: 1. If the total amount of tax payable is not paid before 31st December 2015, the declaration will be treated as void and shall be deemed never to have been made. 2. If the declaration is made by misrepresentation or suppression of facts it shall be void and shall be deemed never to have been made.