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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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..... d 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 substantial shareholder (being a beneficial owner of equity sha .....

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..... t 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 Enclose a copy of the certificate of registration under the Securities and Exchange Board of India Act, 1992. Enclose a copy of the Venture Capital Fund deed in case of Venture Capital Fund registered under the provisions of the Registration Act, 1908. Enclose audited accounts including balance sheet, annual report, if any, with certified copies of income and appropriation towards distribution of income or credit of income [including amount deemed to have been credited in accordance with provisions of section 115 U(5)]. I, ______ .....

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..... tuted vide NOTIFICATION NO. 59/2013 dated 05-08-2013 before it was read as "FORM NO.64 [See rule 12 C] 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 1. Name of the Venture Capital Company or Venture Capital Fund and the address of the address of registered office 2. Permanent Account Number 3. Previous year ending 4. Name and address of the Directors of the Venture Capital Company/trustees of the Venture Capital Fund 5. Total income under all heads received from the investments in Venture Capital Undertakings (6+8+10+12) 6. Total income received from the investments in Venture Capital Undertakings under the head 'Long-term cap .....

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..... full and block letters) hereby solemnly declare that to the best of my knowledge and belief what is stated above and in the Annexure(s), including the documents accompanying such Annexure(s), is correct and complete. I further declare that I am furnishing such statement in my capacity as -------------------------(designation) and that I am competent to furnish this statement and verify it. Verified today the ------------------- day of --------------------- Place---------------------- Signature------------------- Verification I/We ------------------------------------- have examined the books of account and other documents showing the particulars of income earned and the income distributed to the investors by the ----------------------- .....

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