Report from an accountant to be furnished for the purpose of section 9(12) [Schedule I: Paragraph 1(4)] regarding fulfilment of certain conditions by an eligible investment fund

Part A: Particulars ofthe Fund Manager

1.

Name:

(refer Note 1)

2.

Address:

(refer Note 2)

3.

Permanent Account Number (PAN):

(refer Note 3)

4.

Nature of business or activities of the fund manager:

5.

E-mail Id:

6.

Contact Number:

Country

Code

Number

Part B: Other Information

7.

Status:

(refer Note 4)

8.

Residential Status:

(refer Note 5)

9.

Tax Year:

10.

Details of SEBI registration:

(i)

Regulation under which registered:

(ii)

Registration Number and Date:

(iii)

Foreign portfolio investor category, if applicable:

11.

Whether Fund Manager and Fund are related in terms of provision under section 162:

Yes/No

12.

Aggregate value of remuneration received from the eligible fund/funds as per books of account:

13.

List of eligible investment funds for whom the fund manager has undertaken the fund management activity, with the following details:

Sl.

No.

Name of the Offshore Fund

Country of

the residence of the fund

Whether the fund

manager is

an employee of the fund

(Yes/No)

Whether the fund

manager is a connected

person of the fund

(Yes/ No)

The amount

of profit

accruing or arising,

during the tax

year to the

fund from the activities

carried out

through the

fund manager

The amount

out of (F) to

which the fund

manager

along with

its connected

persons is,

directly or indirectly,

entitled to

A

B

C

D

E

F

G

1.

2.

(Repeat, if required)

14.

Particulars of remuneration received in respect of each eligible investment fund and each activity undertaken (if such activity is separately remunerated):

Sl.

No.

Name of the fund for which the fund management activity has been undertaken

Address of

the fund

Description of the activity

Total amount received or receivable in respect of the activity

As per books of account

As computed

by the fund manager

having

regard to the amount

prescribed in this behalf

A

B

C

D

E

F

1.

2.

(Repeat, if required)

15.

Particulars in respect of any other transaction undertaken by the fund manager with/on behalf of the eligible investment fund:

Sl.

No.

Name of the eligible investment fund with which the transaction has been entered or to whom services have been rendered

Address of

the eligible investment

fund

Description of the

transaction/

nature of service

Amount paid / received or payable / receivable on account of such transaction / service

Method used for

determining

the arm‘s

length price

(see section 165)

As per books of account

As computed

by the fund manager

having

regard to the

arm‘s length price

A

B

C

D

E

F

G

1.

2.

(Repeat, if required)

I have examined the accounts and records of   (name and address of the fund manager with PAN) relating the fund management activity and other transactions or services rendered by the fund manager to the eligible investment fund/funds during the tax year ending on 31st March.

2. In my opinion proper information and documents as are prescribed have been kept by the fund manager in respect of fund management activity and other transactions or services rendered by the fund manager to the fund/funds so far as appears from my examination of the records of the fund manager.

3. The particulars required to be furnished for the purpose of section 9(12) [Schedule I: Paragraph 1(4)] are given in Part A and B. In my opinion and to the best of my/our information and according to the explanations given to me the particulars given in Part A and B are true and correct.

(I)

Individual

(II)

Hindu undivided family

(III)

Company

(IV)

Firm

(V)

Association of Persons or Body of individuals, whether incorporated or not

(VI)

Local authority

(VII)

Artificial Juridical Person

(VIII)

Government

(IX)

Trust

(X)

Limited Liability Partnership

(I)

Resident

(II)

Non-resident

(III)

Resident but Not Ordinarily Resident