Form for furnishing the certificate under section 420(4)

To

(Designation of the Prescribed Authority)

I give below the necessary particulars as required under section 420(4):

Part A: Personal Information

1.

Name

(Refer Note 1)

2.

Name of Father/Husband*

(Refer Note 1)

3.

Permanent Account Number (if applicable)

4.

Address

(Refer Note 2)

5.

Contact details

Mobile Number

Country Code

Number

Email ID

6.

Nature of Business/Profession in India

7.

Purpose of visit outside India

8.

Estimated period of stay outside India

9.

Passport Number/Emergency Certificate Number details

(i)

Passport/Emergency certificate number

(ii)

Date of Issue

dd/mm/yyyy

(iii)

Country where issued

(iv)

Place where issued

I hereby certify that:

(a) *No permanent account number has been allotted to me under the provisions of section 262 or under provisions of the Income-tax Act, 1961 (43 of 1961) (as it existed prior to its repeal);

or

(b) *My total income computed in accordance with the provisions of the Act is not chargeable to tax; or

(c ) *I am not required to obtain a permanent account number under the provisions of the Act or under provisions of the Income-tax Act, 1961 (43 of 1961) (as it existed prior to its repeal);

Verification

I, , do hereby declare that the information provided above is true and correct to the best of my knowledge. I have not concealed any relevant fact.

*Delete whichever is not applicable.

Place:

Date:

(Signature of the person giving the certificate)

Name:

Designation: