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Statement of Income distributed by Venture Capital Company or a Venture Capital Fund to be furnished under section 115U of the Income-tax Act, 1961

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..... ecurities and Exchange Board of India (Venture Capital Funds) Regulations, 1996 (ii) under the Securities and Exchange Board of India (Alternate Investment Funds) Regulations, 2012 7. In a case where Venture Capital Company or Venture Capital Fund is registered under SEBI (Alternate Investment Fund) Regulations, 2012, A. Whether the Venture Capital Company or Venture Capital Fund has invested not less than two-third of its investible funds in unlisted equity shares or equity linked instruments of venture capital undertaking : Yes/No B. Whether the Venture Capital Company or the Venture Capital Fund has made any investment in any venture capital undertaking in which, - (i) its director or a sub .....

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..... Name(s) Addresses 2 [ Permanent Account Number or Aadhaar Number ] Total amount paid/ credited Amount paid/ credited under Long Term Capital Gains [Column 5 x Sl.No.10] Amount paid/ credited under Short Term Capital Gains [Column 5 x Sl.No.12] Amount paid/credited as dividend [Column 5 x Sl.No.14] Other Income such as interest etc. paid/ credited [Column 5 x Sl.No.16] 1 2 3 4 5 6 7 8 9 .....

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..... een credited in accordance with provisions of section 115 U(5) to the investors by the ____________________________ (name of the Venture Capital Company or the Venture Capital Fund) for the previous year ending ____________. 2. I./We declare that the above particulars are true and correct to the best of my/our knowledge and belief ______________________ Place _______________ Date ________________ _________________________________ (Signature with name of the Accountant) Notes 1. Accountant means the accountant as defined in the Explanation to sub-section (2) of section 288 of the Income-tax Act, 1961. 2. *Strike out whichever is not applicable. ] ******* NOTES:- 1. Substituted vide .....

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..... ome-tax Total amount paid Amount paid under Long term capital gains [Column 6 X Sl.No.7] Amount paid under Short term capital gains [Column 6 X Sl.No.9] Amount paid as Dividend [Column 6 X Sl.No.11] Other income such as interest, etc., paid [Column 6 X Sl.No.13] (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) .....

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..... ------------------------------------------------------------ (name of the Venture Capital Company or the Venture Capital Fund) for the previous year ending---------------------- 2. I/We declare that the above particulars are true and correct to the best of my/our knowledge and belief. (Signature with name of the accountant) Place--------------- Date---------------- Note 1: Accountant means the accountant as defined in the Explanation to sub-section(2) of section 288 of the Income-tax Act, 1961. 2. Substituted vide Notification No. 95/2019 dated 06-11-2019 w.e.f. 01-09-2019 before it was read as PAN - Forms Tax Manageme .....

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