Clearance Certificate under section 420(5)

DIN Number:

GOVERNMENT OF INDIA

This is to certify that the below mentioned applicant has — *(a) no liabilities outstanding;

*(b) made satisfactory arrangements for the payment of taxes which are or may become payable under the Act, or Income-tax Act, 1961 (43 of 1961) (as it existed prior to its repeal), or under Black Money (Undisclosed Foreign Income and Assets) and Imposition of Tax Act, 2015 (22 of 2015) or under Wealth-tax Act, 1957 (27 of 1957), or under the Gift-tax Act, 1958 (18 of 1958) (as it existed prior to its repeal) or under Expenditure-tax Act, 1987 (35 of 1987).

This certificate is valid for a journey or journeys to be commenced on or after and before

______________

Part-A: Information of the person leaving India

1.

Name

(Refer Note 1)

2.

Name of Father/Husband*

(Refer Note 1)

3.

Permanent Account Number (if applicable)

4.

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

*Delete whichever is not applicable.

Place:

Date:

(Seal)

(Assessing Officer)