Statement or Correction Statement to be filed by Donee under section 354(1)

Part A: Particulars ofthe Reporting Person

1.

Name:

(refer Note 1)

2.

Address:

(refer Note 2)

3.

Permanent Account Number (PAN):

4.

Unique Registration Number (URN):

5.

Date of issuance of URN:

6.

E-mail Id:

7.

Contact Number:

Country

Code

Number

8.

Reporting Period:

From

(dd/mm/yyyy)

To

(dd/mm/yyyy)

Part B: Details in respect of the donors and donations

Sl.

No.

Pre-

Acknowledgement

Number

Unique

Identification

Number (ID)

of the donor

(refer Note

3)

ID

Code

(refer

Note

3)

Name

of

donor

Address

of

donor

Donation

Type

(refer

Note 4)

Mode

of

Receipt

(refer

Note 5)

Amount

of

donation

A

B

C

D

E

F

G

H

I

Undertaking

I, hereby affirm that the details given in the form are true and correct to the best of my knowledge and belief. I undertake to communicate forth with any alteration in the particulars submitted, made at any time hereafter. I further declare that I am filing this form in my capacity as   (designation) having PAN and that I am competent to file this form and verify it.

Type of Identification

ID Code

PAN

1

Type of Identification

ID Code

Passport number

2

Elector‘s photo identity number

3

Taxpayer Identification Number of the country

where the person resides

4

(I)

Corpus donation as per section 339

(II)

Voluntary contribution other than corpus donation

(III)

Specific grant

(IV)

Donation from Corporate Social Responsibility funds as referred to in section 135 of the Companies 2013 (18 of 2013)

(V)

Others, specify

(I)

Cash

(II)

Kind

(III)

Electronic modes NEFT/RTGS including account payee cheque/draft

(IV)

Others, specify