Application for Certificate under section 420(5)

To

The Assessing Officer,

Sir/Madam,

I request that Tax Clearance Certificate be granted to me. I hereby apply for a Tax clearance Certificate in view of my departure from India as required under section 420(5) for which the details required are given as under:

1.

Name

(Refer Note 1)

2.

Name of Father/Husband*

(Refer Note 1)

3.

Permanent Account Number (if available)

4.

Domicile

5.

Nationality

6.

Present Address

(Refer Note 2)

7.

Permanent Address

(Refer Note 2)

8.

Contact details

Mobile Number

Country Code

Number

Email ID

9.

Nature of Business/Profession in India

10.

Address of all the places of Business/Profession in India

(Refer Note 2)

(Repeat, if required)

11.

Details of previous visits outside India:

(i)

Date of arrival in India

dd/mm/yyyy

(Repeat, if required)

(ii)

Period of stay outside India

(Repeat, if required)

12.

Purpose of visit outside India

13.

Departure Details

(i)

Date of departure

dd/mm/yyyy

(ii)

Details of flight/ship/road journey by which travel is being undertaken

14.

(i)

Whether exemption is claimed under any section of the Act?

(Select One)

(i) Yes

(ii) No

(ii)

If the answer to row 14(i) is yes, then provide section of the

Act

15.

Destination of journey

16.

Date of Intended Return

dd/mm/yyyy

17.

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

Verification

I, hereby declare that I have no liability under the Act or the Income-tax Act, 1961 (43 of 1961) (as it existed prior to its repeal) or the Wealth-tax Act, 1957 (27 of 1957) or the Gift-tax Act, 1958 (18 of 1958) (as it existed prior to its repeal) or the Expenditure-tax Act, 1987 (35 of 1987) or the Black Money (Undisclosed Foreign Income and Assets) and Imposition of Tax Act, 2015 (22 of 2015), or that satisfactory arrangements have been made for the payment of all or any of such taxes which are or may become payable by me.

Further, 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)

Name:

Designation: