Application by a person under section 434 for refund of tax deducted

To

The Assessing Officer,

This application is filed to seek refund of the tax deducted and paid to the credit of Central Government, the particu- lars of which are as under:

Part-A: Details of the Applicant

1.

Name

(Refer Note 1)

2.

Address

(Refer Note 2)

3.

Status

(Refer Note 3)

4.

Name of Father/Husband*

(Refer Note 1)

5.

Residential status

(Select One)

(vii) Resident

(viii) Resident but not

ordinarily resident

(ix) Non-resident

6.

Permanent Account Number

7.

Contact details

Mobile Number

Country Code

Number

Email ID

Part-B: Detail of the Deductee

8.

Name

(Refer Note 1)

9.

Status

(Refer Note 3)

10.

Permanent Account Number (if available)

11.

Tax Identification Number (TIN), if any

(Refer Note 4)

12.

Contact Details

Mobile Number

Country Code

Number

Email ID

13.

Country of which the deductee was a resident in the relevant tax Year

Part-C: Details of agreement or other arrangement

14.

Date of signing the agreement or other arrangement

dd/mm/yyyy

15.

Date on which the agreement or other arrangement came into effect

dd/mm/yyyy

16.

Time Period for which the agreement or other arrangement

is effective

17.

Proof of Agreement

(Refer Note 5)

Part-D: Details of transaction on which tax not deductible has been deducted

18.

Amount of transaction

19.

Date of transaction

dd/mm/yyyy

20.

Date of payment made

dd/mm/yyyy

21.

(i)

Mode of payment

(ii)

Attach proof of payment of row 21(i)

(Refer Note 5)

22.

Nature of transaction

Part-E: Details of tax deducted on transaction specified in Part D above

23.

Amount of tax deducted

24.

Date of tax deduction

dd/mm/yyyy

25.

Date on which the tax deducted was deposited in Government Account

dd/mm/yyyy

26.

Details of challan

S No

BSR

Code

Date of deposit in Gov- ernment Account

Serial number of

challan.

Amount

27.

Please explain why no tax was required to be deducted on the income in the relevant transaction

28.

(A)

Please state whether tax deducted on similar transaction has been refunded in 3 years prior to the relevant tax year?

(Select One)

(i) Yes

(ii) No

(B)

If the answer to row 28(A) is yes, then provide following:

(i)

Tax year

(ii)

Date of transaction

dd/mm/yyyy

(iii)

Amount of tax deducted

(iv)

Amount of tax refunded

(v)

Date of order of Commissioner (Appeals) or the Assessing Officer, as the case may be

dd/mm/yyyy

(vi)

Attach copy of Order mentioned in row 28(B)(v)

(Refer Note 5)

29.

Please specify other relevant details (if any)

(Refer Note 5)

Verification

I, [name in full and in block letters] *son/daughter/spouse of having PAN of [name of the entity], do hereby declare that to the best of my knowledge and belief what is stated above is correct, complete and truly stated. I declare that no tax was required to be deducted on the income referred to in this form. I further declare that what is stated in this application is cor- rect. I also declare that I am making this application in my capacity as [designation] and I am also competent to make this application and verify it.

*Delete whichever is not applicable

Place:

Date:

(Signature)

Name:

Designation:

Address:

Sl No.

Annexure

Remarks

1.

A-1

Proof of Agreement in row 17.

2.

A-2

Proof of payment in row 21(ii).

3.

A-3

Attach copy of Order in row 28(vi)

4.

A-4

Any other details in row 29.