Statement of income distributed by an investment fund to be provided to the unit holder under section 115UB of the Income-tax Act, 1961

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..... redited by the Investment Fund to the unit holder during the previous year: (In Rs) S. No. Amount paid or credited Date of payment or credit Breakup of Amount paid/ credited under Heads of Income Business or Profession Long Term Capital Gain Short Term Capital Gain Other Sources Chargeable @10% u/s 112A Chargeable @10% (other than section 112A) Chargeab le @20% Chargeable @15% 111A Chargeable @30% C .....

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..... (1) (2) (3) (4) I, _____________________________________(Name in full and in block letters) son/daughter/ wife of _________________________do 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 ___________ Sign .....

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..... 9; Referred to in Section 10(38) Others To which Section 111A applies Others 'Dividend' [referred to in Section 115O ] Others (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) I, _______________________________ (Name in full and in block lett .....

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