Form to be filed by the deductor, if he claims refund of sum paid under Chapter XIX of the Act
Row No. | Part A: Particulars ofthe Deductor | ||
1. | Name | (refer Note 1) | |
2. | Address | (refer Note 2) | |
3. | Permanent Account Number | ||
4. | Tax Deduction and Collection Account Number, if applicable | ||
5. | Email id | ||
6. | Contact number | Country Code | Number |
7. | Bank account Number | ||
8. | IFSC Code | ||
9. | Type of account (as applicable) | ||
10. | Legal entity identification number (if applicable) | (refer Note 3) | |
PART B | |||||||||
I. Details of sum paid in the Central Government account through challans out of which refund is being claimed. | II. Detail of sum paid under Chapter XIX by the deductor for which credit has been claimed in the statement furnished under section 397(3)(b) (out of amount mentioned in column 3). | ||||||||
Ro w No (1) | Challan Identification number (CIN) (2) | Amount (3) | Tax year (4) | Statements in which challan has been utilised (refer Note 4) (5) | Receipt number/ acknowledgement number of relevant statements (6) | Amount utilised in statement referred to in column (6) (7) | Amount of refund claimed (8) [3-7] | ||
BSR Code of the Bank Branch | Date on which tax deposited (dd/mm/yyyy) | Challan Serial Number | |||||||
1 | |||||||||
2 | |||||||||
Total (₹) | Total (₹) | ||||||||
DECLARATION
I, … … … … … … … … … … .. having Permanent Account Number ………… working in the capacity of … … … … … … … … … .. (designation) do hereby certify that a total sum of rupees … … … … … … . (in words) [mentioned in column (8) above] has been deducted and deposited to the credit of the Central Government and the same has not been claimed and shall not be claimed in any of the statement to be furnished under section 397(3)(b).
I further certify that the information given above is true, complete and correct and is based on the books of account, documents, relevant statements, tax deposited and other available records.
Place: Signature
Date: Name:
Designation:
Notes:
1. In case of individual, the first, middle and last name shall be provided in full without any abbreviations with the appropriate title (Mr./Mrs./Ms.). In any other case also, name shall be provided in full.
2. The address shall contain i. Country/Region, ii. Flat/Door/Building, iii. Road/Street/ Block/Sector, iv. PIN/ZIP Code, v. Post Office, vi. Area/locality, vii. District, viii. State.
3. Legal entity identification number is required to be furnished only where the refund amount claimed is 50 crore rupees or above.
4. Mention all the statements in which the challan has been utilised.
5. Some of the information in the form would be pre-filled to the extent possible.
6. Amounts to be filled in ₹ unless otherwise provided.