Form of application under section 270AA(2) of the Income-tax Act, 1961

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..... Flat/ Door/ Block No. Name of Premises/ Building/ Village Road/ Street/ Post Office Area/ Locality Town/City/District State Country Pin Code Phone No. with STD code/ Mobile No. Email Address Det .....

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..... Details of amounts paid Sl. No. BSR Code Date of Deposit (DD/MM/YYYY) Serial Number of Challan Amount (Rs.) (i) .....

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..... Form of verification I, ____________________________son/daughter* of_____ .....

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