Form of application under section 440(2)

1.

Name

(Refer Note 1)

2.

Permanent Account Number

3.

Father’s/Husband’s name

(Refer Note 1)

4.

Address

(Refer Note 2)

5.

Contact details

(i)

Mobile Number

Country Code

Number

(ii)

Email ID

Part B: Details of orders and payments

6.

Tax Year

7.

Section under which assessment/reassessment*order is passed

8.

Date of the assessment/reassessment*order

dd/mm/yyyy

9.

Date of service of the assessment/reassessment*order

dd/mm/yyyy

10.

Amount of income assessed as per the assessment/reassessment* order

11.

Tax and interest payable as per notice of demand

12.

Due date for payment as per notice of demand

dd/mm/yyyy

13.

Details of amounts paid

(A)

(i)

BSR Code

(ii)

Date of Deposit

dd/mm/yyyy

(iii)

Serial Number of Challan

(iv)

Amount

(B)

(repeat as required)

Verification

I, , PAN , do hereby declare that what is stated above is true to the best of my information and belief. I further declare that no appeal has been filed in respect of the order mentioned in Part-B above. I also undertake that no appeal shall be filed in respect of the said order before the expiry of the period specified in section 440(5). I further declare that I am making this application in my capacity as   and I am also competent to file this application and verify it. Verified today the  day of 20 .

Place Signature,

Date Name

Designation (if applicable)