Statement of exempt income under Schedule VI [Table: Sl. No. 10]

Part A: Particulars ofthe Specified Fund

1.

Name:

(refer Note 1)

2.

Address:

(refer Note 2)

3.

Permanent Account Number (PAN):

4.

E-mail Id:

5.

Contact Number:

Country

Code

Number

Part B: Other Details

6.

Tax Year:

7.

Legal status of the specified fund (refer Note 3):

(select one)

8.

Date of establishment/incorporation:

9.

Date of commencement of operations:

10.

Registration Details:

(i)

Registration number as per the certificate of registration issued by the International Financial Services Centres Authority

(ii)

Date of registration:

11.

Whether all the units of the specified Fund are held by non-residents other than units held by a sponsor or a manager:

12.

Name of the original fund and its wholly owned special purpose vehicle:

13.

Registered address of the original fund and its wholly owned special purpose vehicle:

(refer Note 2)

14.

Whether the original fund is a person resident in India:

Yes/No

15.

Whether the original fund is a resident of a country or a specified territory with which an agreement referred to in section 159(1) or section 159(2) has been entered into; or is established or incorporated or registered in a country or a specified territory as may be notified by the Central Government in this behalf:

Yes/No

16.

Whether the original fund and its activities are subject to applicable investor protection regulations in the country or specified territory where it is established or incorporated or is a resident:

Yes/No

17.

Whether the original fund fulfils conditions as may be prescribed under section 70(1)(u):

Yes/No

18.

Country of residence of the original fund:

19.

Legal status of the original fund and its wholly owned special purpose vehicle (refer Note 3):

(select one)

20.

Taxpayer‘s registration number or any unique identification number of the original fund allotted and its wholly owned special purpose vehicle in the country of residence:

21.

Details of the shares transferred:

Sl.

No.

Name of the

company resident in

India whose shares

are transferred

Number of

Shares

Date of

acquisition

Cost of

acquisition

Date of

transfer

Sale

consideration

A

B

C

D

E

F

G

1.

2.

(Repeat, if required)

22.

Computation of the exempt income under Schedule VI [Table: Sl. No. 10]:

(i)

Income of the nature of capital gains, arising or received by the resultant fund, on account of transfer of share of a company resident in India [1]:

(ii)

Aggregate value of daily 'assets under management' of the specified fund held by non-resident unit holders (not being the permanent establishment of a non-resident in India), from the date of acquisition of the share of a company resident in India by the specified fund to the date of transfer of such share [2]:

(iii)

Aggregate value of daily total 'assets under management' of the specified fund, from the date of acquisition of the share of a company resident in India by the specified fund to the date of transfer of such share [3]:

(iv)

Ratio as prescribed under rule 285 [4]:

[2] / [3]

(v)

Income attributable to units held by non-resident (not being a permanent establishment of a non-resident in India) [5]:

[1] × [4]

Verification

This is to certify that all the details of the specified fund, including details of exempt income, 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.

It is also verified that the certification of the accountant in Form No. 179 has been filed on .

(I)

Company

(II)

Trust

(III)

Limited Liability Partnership

(IV)

Body Corporate