Application for grant of approval to a fund referred to in Schedule VII [Table: Sl. No. 2]

Part A: Particulars ofthe Applicant (Trust/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

(drop down)

Part B: Other Information

6.

Name of the employer organisation (in which the members of the fund are employed)

7.

PAN of the employer organisation

8.

Objects of the fund:

(refer Note 3)

9.

Names and addresses of trustees/office bearers ofthe fund:

Sl.

No.

Name of trustee(s)

Address

PAN

1.

2.

(Repeat, if required)

10.

Classes and number of employees admitted to the fund:

(i)

in India:

Sl.

No.

Classes

Number

1.

2.

(Repeat, if required)

(ii)

outside India:

Sl.

No.

Classes

Number

1.

2.

(Repeat, if required)

11.

Whether contribution to the fund is made by employees by periodical subscription:

Yes/No

12.

Total amount of accretion during the tax year:

Amount contributed by the employees

Income accrued during the tax year

13.

Whether the trust proposes to apply or accumulate funds for application wholly and exclusively for the purposes mentioned in Sl. No. 8:

Yes/No

14.

Details of investments/ deposits in one or more of the modes specified under section 350:

Sl.

No.

Name of instrument/ security/ scheme, etc.

Value

Income received thereon

15.

Details of investments/ deposits in any mode other than specified under section 350:

Sl.

No.

Name of instrument/ security/ scheme, etc.

Value

Income received thereon

16.

Other details to be provided as separate enclosure:

(attach as per Note 4)

Verification

I, , in the capacity of the trustee/principal officer, having PAN , do hereby declare that the information furnished above is correct and complete to the best of my knowledge and belief, and I am competent to file and verify this form on behalf of the trust/fund mentioned at Part A (Sl. No. 1).

I undertake to communicate forthwith any alteration in the terms of the trust deed of the fund, or in the rules governing the fund made at any time hereafter.

(a)

Cash benefits to a member on superannuation

(b)

Cash benefits to a member in the event of illness of self, spouse or dependent children

(c)

Cash benefits to a member to meet the cost of education of dependent children

(d)

Cash benefits to a member to meet the cost of annual medical tests or medical check-ups of self, spouse and dependent children

(e)

Cash benefits to the dependents ofa member in the event of death of such member

(f)

Any other, specify

Anne

xure

Particulars

A-1

A copy of the instrument of trust evidencing the formation of the fund

A-2

Notes on activities of the fund for the period since its inception or during the last three years, whichever is less

A-3

Copies of accounts of the fund for the period since its inception or during the last three years, whichever is less