Statement of eligible investment received

Part A: Particulars of the Assessee

1.

Name:

(refer Note 1)

2.

Address:

(refer Note 2)

3.

Permanent Account Number (PAN):

4.

Tax Year

5.

E-mail Id:

6.

Contact Number:

Country

Code

Number

Part B: Details of the Investment received

7.

Details of eligible investments received, on or after the date of notification of the specified person, from the specified person or eligible Alternative Investment Fund out of the investment of the specified person:

Sl

.

N

o.

Name

PAN

Opening balance of eligible investments received

Eligible investments

received during the year

Eligible investments returned during the

year

Closing balance of eligible investments

received

A

B

C

D

E

F

G

1.

2.

Total

8.

Details of all the investments made out of the eligible investments listed in Sl. No. 7:

S l

.

N

o

.

N

a

m

e

Date of

inve

stme nt

Nature of

invest ment (refer Note 3)

Details of the

entity in which

Investment is made

Openi ng

balan

ce of the

invest

ment

Amo

unt of

invest

ment

made

durin

g the year

Amount of

investm ent

sold/liq

uidated

during

the year

Date of

investme

nt or date of

sale/liqui dation,

as the case

maybe

Clos

ing

bala

nce of the

inve

stme nt

Natu

re of

inco me (refe r

Note 4)

Inco me on

invest

ment

durin

g the year

Out of the

income in

column N

Nature of

income to the

specified person/

eligible

Alternativ e

Investme nt Fund

Inco me to the

specif ied

perso n/

eligib le

Alter

native

Inves

tment

Fund

Na

tur

e

of

ent

ity

(re

fer

No

te

5)

Nam

e of

entit y

P

A

N

of

th

e

en

tit

y

A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

1

.

2

.

Total

9.

Details of investment received from specified person or eligible Alternative Investment Fund listed in Sl. No. 7, but the investment not covered in Sl. No. 7:

Sl.

No.

Name, listed at Sl. No. 7

PAN

Opening balance

of the

investments

received not

Investments received during the year not

covered in Sl. No. 7

Investments

returned during the year

Closing

balance of investments

received

covered in Sl. No. 7

A

B

C

D

E

F

G

1.

2.

Total

10.

Details of all the investments made out of the investments listed in Sl. No. 9:

Sl

.

N

o.

N

a

m

e

Date of

inve

stme nt

Nature of

invest ment (refer Note 3)

Details of the

entity in which

Investment is made

Openi ng

balan

ce of the

invest

ment

Amo

unt of

invest

ment

made

durin

g the year

Amount of

investm ent

sold/liq

uidated

during

the year

Date of

investme

nt or date of

sale/liqui dation,

as the case

maybe

Clos

ing

bala

nce of the

inve

stme nt

Natu

re of

inco me (refe r

Note 4)

Inco me on

invest

ment

durin

g the year

Out

of the

incom

e in

colum n N, Natur

e of

incom

e to the

specif ied

perso n/

eligibl e

Altern ative Invest ment Fund

Incom

e to the

specifi ed

person /

eligibl e

Altern ative Invest ment Fund

Na

tur

e

of

ent

ity

(re

fer

No

te

5)

Nam

e of

entit y

P

A

N

of

th

e

en

tit

y

A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

1.

2.

Total

Declaration

This is to certify that the details of investment declared above are true to the best of my knowledge and belief. I also affirm that I am making this application in my capacity as (designation) and that I am holding PAN and I am competent to make this application and verify it.

Nature of Investment

Code

Debt

1

Equity

2

Preference Shares

3

Others (Please specify)

4

Nature of Income

Code

Interest

1

Dividends

2

Capital Gains

3

Others (Please specify)

4

Nature of entity in which investment is made

Code

Business Trust referred to in Schedule V [Table: Sl. No. 7.D(a)(iii)(A)]

1

Eligible Infrastructure Facility referred to in Schedule V [Table: Sl. No. 7.D(a)(iii)(B)]

2

Eligible Alternative Investment Fund referred to in Schedule V [Table: Sl. No. 7.D(a)(iii)(C)]

3

Eligible Domestic Company referred to in Schedule V [Table: Sl. No.

7.D(a)(iii)(D)]

4

Eligible Non-Banking Financial Company referred to in Schedule V [Table: Sl. No. 7.D(a)(iii)(E)]

5