Details of amount attributed to capital asset remaining with the specified entity

1.

Details of the specified entity

(i)

Name

(refer note 1)

(ii)

Address

(refer note 2)

(iii)

Permanent Account Number

2.

Tax Year

3.

Amount taxable under section 67(10)

4.

Attribution of amount taxable under section 67(10) to capital assets remaining with the specified entity

(i)

Details of the Capital Asset

Book

Value

Revalued amount / valued amount for self- generated asset

Amount

attributed

Sr. No

Name

Whether self- generated

(select one)

Nature of

capital asset

(select one)

(a)

1. Yes

2. No

Short term

Long term

(b)

1. Yes

2. No

Short term

Long term

(c)

1. Yes

2. No

Short term

Long term

(d)

1. Yes

2. No

Short term

Long term

(e)

(REPEAT if required)

(ii)

TOTAL

5.

Details of valuer based on whose valuation report information at row 4 is provided

(i)

Name

(refer note 1)

(ii)

Registration Number

6.

Copy of the Valuation Report

UPLOAD

Declaration

I, (name) holding Permanent Account Number solemnly declare that to the best of my

knowledge and belief, the information given in the form is correct and complete and is in accordance with the provisions of the Act. I further declare that I am furnishing the form in my capacity as and I am also competent to furnish this form and verify it.

Signature

Place:

Date:

Name:

Designation: