Certificate under section 413 or 414.

Date

To

(PAN/Aadhaar)

Part A: Basic Information

1.

Name

(Refer Note 1)

2.

Permanent Account Number

3.

Address

(Refer Note 2)

4.

Status

(Refer Note 3)

5.

Contact details

Mobile No.

Country Code

Number

Email ID

Part B: Details of Amount in Arrears

6.

Tax Year

7.

A.

Income Tax

(i)

Regular

(ii)

Advance

(iii)

Provisional

(iv)

Total

B.

Surcharge

(i)

Regular

(ii)

Advance

(iii)

Provisional

(iv)

Total

C.

Additional tax under section 270

(i)

Regular

(ii)

Advance

(iii)

Provisional

(iv)

Total

D.

Penalty under section

(i)

Regular

(ii)

Advance

(iii)

Provisional

(iv)

Total

E.

Interest under section

(i)

Regular

(ii)

Advance

(iii)

Provisional

(iv)

Total

F.

Fine under section 246

(i)

Regular

(ii)

Advance

(iii)

Provisional

(iv)

Total

G.

Interest under section 411(3) from the day when amount became due

(i)

Regular

(ii)

Advance

(iii)

Provisional

(iv)

Total

H.

Any other sum

(i)

Regular

(ii)

Advance

(iii)

Provisional

(iv)

Total

8.

Aggregate of 7(A)(iv), 7(B)(iv), 7(C)(iv), 7(D)(iv), 7(E)(iv), 7(F)(iv), 7(G)(iv), 7(H)(iv)

9.

(Repeat row 6 to 8, if required)

1. *This is to certify that a sum of has become due from you on details of which are given above.

Whereas a certificate bearing Document Identification Number dated had been forwarded by the Tax Recovery Officer, [name of the place], for the recovery of sum of details of which are given above and the said Tax Recovery Officer has sent a certified copy of the said certificate to the undersigned under section under section 414, specifying a sum of which is to be recovered from you.

2. You are hereby directed to pay the above sum within 15 days of the receipt of this notice failing which the recovery shall be made in accordance with the provisions of section 413 to section 422, and the rule 225 to the said Income Tax Rules 2026.

3. In addition to the sums aforesaid, you will also be liable for, -

(a) such interest as is payable in accordance with section 411(3) for the period commencing immediately after the issue of this notice;

(b) all costs, charges and expenses incurred in respect of the services of this notice and of warrants and other processes and all other proceedings taken for realizing the arrears.

*Delete whichever is not applicable

Date:

Place:

(Seal)

(Tax Recovery Officer)