Certificate under section 152(5) of the Act for Patentees in receipt of royalty income

Part –A

Basic Information

1.

Details of the Patentee

(i)

Name

(refer Note 1)

(ii)

Address

(refer Note 2)

(iii)

Permanent Account Number

2.

Tax year

Part - B

3.

Details of Patent

(i)

Registration Number

(ii)

Date of registration

dd/mm/yyyy

(iii)

Title

(iv)

Location of the patent office where the patent register is maintained

(v)

Whether the patent is in the nature of patent of addition

(select one)

1. Yes

2. No

(vi)

If answer to (v) above is “Yes” then:

(a)

title of original patent

(b)

registration of original patent

4.

Details of the Patentee

(i)

Whether the patentee is the true and first inventor of the invention?

(select one)

1. Yes

2. No

(ii)

Date on which the name of patentee was entered on the patent register?

dd/mm/yyyy

(iii)

Whether the name of the patentee was revoked or excluded from the patent register in respect of patent mentioned at row 3?

(select one)

1. Yes

2. No

(iv)

If reply to (iii) is yes, the date from which such revocation or exclusion took place?

dd/mm/yyyy

5.

(i)

Whether compulsory license has been issued by the Controller in respect of the patent mentioned at row 3?

1. Yes

2. No

(ii)

If yes, royalty income settled in terms of any compulsory license?

6.

Details of the person paying royalty income from patent

(i)

Name

(refer Note 1)

(ii)

Address

(refer Note 2)

(iii)

Permanent Account Number, as applicable

7.

Details of royalty agreement

(i)

Nature of royalty

(select one)

(a) transfer of all or any rights (including the granting of a license) in respect of the patent

(b) imparting of any information concerning the working

of, or the use of, the patent

(c) use of the patent

(d) rendering of any services in connection with the activi- ties referred to in sub-clauses (a) to (c)

(e) consideration for sale of products manufactured with the use of patented process or the patented article for commercial use

(ii)

Period for which the agreement is applicable

dd/mm/yyyy to dd/mm/yyyy

(iii)

Amount of royalty income payable for the tax year (in ₹)

8

Details of payment for royalty received

(i)

In Indian rupees (in ₹)

(ii)

In foreign currency (value in ₹)

Total amount

payable during

the year

Amount

actually

paid

Date of

payment

Mode of

payment

(iii)

Total Payment [(i) + (ii)]

9.

Amount brought into India in convertible foreign exchange

(i)

within a period of six months from the end of the tax year

(ii)

within such further period as allowed by the Competent authority

Name of the

competent

authority

Further period

allowed till

(dd/mm/yyyy)

Amount

10.

Amount of deduction claimed

<<TO BE FILLED BY THE ASSESSEE>>

Declaration

I (name), holding Permanent Account Number , hereby affirm that the details declared above are true to the best of my knowledge and belief and the income declared therein is respect of the aforementioned patent is

entitled for deduction under section 152 of the Act.

Signature of the assessee

Name:

Date :

Place :

Part -C <<to be filled by the prescribed authority>>

CERTIFICATION

Certified that details at row 3, 4 and 5 in respect of the patentee at row 1 above are correct and as per the register of patents maintained by this office.

Signature of the Controller of Patents Date:

Place:

Name:

Designation: Address: