Application to the Dispute Resolution Committee under section 379 of the Act

1.

Name

(Refer Note 1)

2.

Address

(Refer Note 2)

3.

Permanent Account Number (PAN)

4.

Tax Deduction and Collection Account Number (if any)

5.

Contact Details

Mobile Number

Country Code

Number

Email ID

Part B: Order against which application is filed

6.

Tax year in connection with which the application is preferred

7.

Details of specified order against which application is filed

(i)

section and sub-section of the Act

(ii)

Date of Order

dd/mm/yyyy

(iii)

Date of service of Order / Notice of Demand

dd/mm/yyyy

8.

Income-tax Authority passing the specified order

Part C: Application Details

9.

(i)

Amount of Income Assessed

(ii)

Total Addition to Income

(iii)

In case of Loss, total disallowance of Loss in assessment

(iv)

Amount of Addition/ Disallowance of Loss disputed in application

(v)

Amount of Disputed Demand (Enter Nil in case of Loss)

Part D: Pending Application

10.

(i)

Whether an application in relation to any other tax year is pending in the case of the assessee with any Dispute Resolution Committee

(Select One)

(i) Yes

(ii) No

If reply to row 10(i) is yes, then provide following

(ii)

Dispute Resolution Committee, with whom the application is pending

(iii)

Application Number

(iv)

Date of filing of Application

dd/mm/yyyy

(v)

Tax year in connection with which the application has been preferred

(vi)

Income-tax Authority passing the specified order

(vii)

section and sub-section of the Act, under which the specified order has been passed

(viii)

Date of such Order

dd/mm/yyyy

Part E: Details of Taxes paid

11.

(i)

Where a return has been filed by the assessee for the

(i) Yes

tax year in connection with which the application is filed, whether tax due on income returned has been paid in full

(Select One)

(ii) No

(iii) Not Applicable

If reply to row 11(i) is Yes, then enter details of Return of Income (RoI) and taxes paid

(ii)

Acknowledgement number

(iii)

Date of filing of RoI

dd/mm/yyyy

(iv)

Total Income as per RoI

(v)

Total tax due as per RoI

(vi)

Total tax paid

Part F: Statement of facts, Grounds of application and additional evidence

12.

Statement ofFacts

(i)

Facts ofthe Case

(Refer Note 3)

(ii)

List of documentary evidence relied upon

13.

(i)

Whether any documentary evidence other than the evidence produced during the course of proceedings before the Income-tax Authority has been filed

(Select One)

(i) Yes

(ii) No

(ii)

If reply to row 13(i) is Yes, furnish the list of such documentary evidence

(Refer Note 3)

14.

Grounds of Application consisting of each ground

(Refer Note 3)

Part G: Application filing details

15.

Details of application Fees Paid

Form of verification

I, [name in full and in block letters] *son/daughter/spouse of

having Permanent Account Number of [name of the entity], do hereby declare that what is stated above is true to the best of my information and belief. It is also certified that no additional evidence other than the evidence stated in row 13(ii) above has been filed. I further

declare that I am making the declaration in my capacity as [designation] and that I am competent to make this declaration and verify it.

Place:

Date:

(Signature)

(Name: ___________) Designation:

Annexure

Particulars

A-1

Facts ofthe Case in row 12(i)

A-2

List of documentary evidence relied upon in row 12(ii)

A-3

List of documentary evidence other than the evidence produced during the course of proceedings before the Income-tax Authority in row 13.

A-4

Grounds of Application consisting each ground in row 14.