Application for change of purpose of accumulation or setting apart of income under section 342(5)

Part A: Particulars ofthe Applicant

1.

Name:

(refer Note 1)

2.

Address:

(refer Note 2)

3.

Permanent Account Number (PAN):

4.

E-mail Id:

5.

Contact Number:

Country Code

Number

6.

Part B: Details of amount accumulated or set apart and proposed change in purpose

Sl

.

N

o.

As per Form No. 109

Proposed change

Tax Year of

accumula ted/

setting apart

Dat

e of

fili ng For m No.

109

Acknowledg ment

Number

Endi ng

tax year

Amount

accumula ted/ set- apart

Amount

accumula

ted/ set-

apart that remains unapplie d

Amount

accumula

ted/ set-

apart for which

change

of

purpose is

requested

[Amount cannot be

greater than

amount in

column G]

Origi nal

purpo se

New

purp

ose

Date of

Resolution

passed by

trustee/Gove rning

body/Manag ing

committee

Reason

for

change of

accumula tion

A

B

C

D

E

F

G

H

I

J

K

L

Verification

I, , holding PAN , solemnly affirm that to the best of my knowledge and belief, the information given in the certificate is correct and complete and is in accordance with the provisions of the Act. I further declare that I am making this certificate in my capacity (designation) and I am also competent to issue this certificate.