Statement to be furnished by an eligible investment fund to the Assessing Officer under section 9(12) [Schedule I: Paragraph 1(4)]

Part A: Particulars ofthe Eligible Investment Fund

1.

Name:

(refer Note 1)

2.

Address:

(refer Note 2)

3.

Permanent Account Number (PAN):

(refer Note 3)

4.

Tax Identification Number (TIN) in the country/region of residence:

5.

Country of residence:

6.

E-mail Id:

7.

Contact Number:

Country

Code

Number

Part B: Other Information

8.

Financial Year for which the statement is being submitted:

9.

Tax Year of the Fund:

10.

Details of Approval if any granted by CBDT:

(i)

Date of approval:

(ii)

Approval order/letter reference number:

11.

Whether during the Tax Year the fund has satisfied all the conditions specified in section 9 [Schedule I] and in case of Approved Fund whether conditions subject to which approval was granted, have also been fulfilled (refer Note 4.A-1):

Yes/No

12.

Whether any person resident in India had any participation interest directly in the fund during the year (refer Note 4.A-2):

Yes/No

13.

Details of any shareholding agreement entered during the year in respect of any Indian Concern:

Sl.

No.

Name of the Indian Concern

PAN

Percentage interest

Date of agreement

1.

2.

(Repeat, if required)

14.

Details of Fund Manager(s) in India rendering services for or on behalf of the Fund:

Sl.

No.

Name of the Fund Manager

PAN

Securities and Exchange Board of India (SEBI) Registration Number

1.

2.

(Repeat, if required)

15.

Whether remuneration paid to the Fund Manager(s) is not less than the amount prescribed (refer Note 4.A-3):

Yes/No

16.

Amount of profit made by the Fund on its investment:

17.

Contact details of the representative(s) of the Fund:

18.

Other details to be provided as separate enclosure:

(attach as per Note 4)

Verification

I, hereby affirm that the information provided above is true and correct to the best of my knowledge. I have not concealed any relevant fact. I am submitting this form in my capacity as  (designation), holding PAN and I am competent to verify and submit this form.

Anne

xure

Particulars

A-1

If No in Part B (Sl. No. 11), provide details and period of non-fulfilment and the reasons thereof: —

Sl. No.

Paragraphs of

Schedule I not fulfilled

From

To

Reasons

1.

2.

(Repeat, if required)

A-2

If Yes in Part B (Sl. No. 12), provide details of person(s) and percentage interest: —

Sl. No.

Name of the Person

Address

PAN

Percentage Interest

1.

2.

(Repeat, if required)

A-3

If Yes in Part B (Sl. No. 15), provide the basis on which remuneration of the Fund Manager has been calculated.

A-4

Details of any other activity carried out by the fund or on behalf of the fund in India other than through the fund manager indicated in Part B (Sl. No. 14).